APPENDICES TO THE
REPORT OF THE SAGE
WORKING GROUP ON
VACCINE HESITANCY
01 October 2014
Table of Contents
Appendix for Section 3 .............................................................................................................................. 2
Appendix A3.1: Review of Models of Determinants of Vaccine Hesitancy ............................................. 2
Appendix for Section 4 .............................................................................................................................. 9
Appendix A4.1: Systematic review on vaccine hesitancy ......................................................................... 9
Appendix A4.2: Mapping vaccine hesitancy- Country specific characteristics of a global phenomenon. 9
Appendix for Section 5 ............................................................................................................................ 23
Appendix A5.1: Pilot Test of Vaccine Confidence Indicators 2012 ......................................................... 23
Appendix 5.2: Pilot Test of Revised 2013 Vaccine Hesitancy Indicators ................................................ 37
Appendix A5.3 Vaccine Hesitancy Survey Questions Related to SAGE Vaccine Hesitancy Matrix ......... 51
Appendix A5.4 WHO EUR Tailoring Immunization Program (TIP) .......................................................... 58
Appendix A5.4.1:Principles for TIP.......................................................................................................... 58
Appendix for Section 6. ........................................................................................................................... 59
Appendix A6A.1 Executive Summary of the Systematic Review on Strategies to address vaccine
hesitancy ................................................................................................................................................. 59
Appendix A6A.2 Strategies to address vaccine hesitancy: summary of published literature reviews ... 72
Appendix A6C.1 Vaccine Hesitancy Landscape Analysis ......................................................................... 92
References ............................................................................................................................................ 107
Appendix for Section 3
Appendix A3.1: Review of Models of Determinants of Vaccine Hesitancy
The 2011 Determinants of Vaccine Hesitancy Model from Canada (Figure A3.1) while
illustrating the wide array of determinants and factors was felt to be thoughtful and useful for
academic work but too complex for practical application in the field.
Figure A 3.1 Determinants of Vaccine Hesitancy: Canadian Model
DETERMINANTS OF VACCINE HESITANCY
Historic, political and
socio-cultural context
Government
Healthcare System
Pharmaceutical
companies
Emotion
Perceived
Severity and
Susceptibility to
VPD
Medical expertise
Rationality
Social
media
Perceived Safety &
Effectiveness of
vaccine
Risk perception and
evaluation
Vaccines and
immunization
VPD
Science
Internet
Communication
and media
Spirituality
Social
support
Ethics
Religious and
cultural
particularities
Empowerment
Self efficacy
Individual reflection
and
decision-making process
Trust
Attitudes
Subjective
norm
Knowledge
and Beliefs
Health promotion
and prevention
Laws/
Incentives
Vaccine
hesitancy
Individual / population
effects
Continuum
Communication
Training
skill
Medical and
Religious epidemiological
literacy
knowledge
refusal
acceptance
Role of healtcare
professionnals
md
RN
Vaccination
promotion &
communication
Role of
Public health
Avoid VPD
epidemic
Vaccine
coverage
Alternative med
Hesitant professionals
Counselling
Impartiality
Recommend
avoiding
vaccination
appearance of
conflict of
interest
Leave time
Relation of
for the
trust
Payment vs
decision to
time spent
be made
counselling
Educating
Patients/parents
Vaccination
programs
Rigorous
evaluation
and
monitoring
Vaccine
delivery
service
Continuity
Vaccination
registers
Relationship
of trust
Adapted from results of the “ Workshop on the cultural and religious roots of vaccine hesitancy: Explanations and implications for the Canadian healthcare system” , Guay and
coll., Sherbrooke University, Longueuil, December 5-6 2012
The Working Group also explored arranging factors that impinge on vaccine hesitancy in a
systems approach matrix that grouped factors into three main categories of influences:
contextual, individual and group and vaccine /vaccination specific influences (Table A3.1,
Figure A3.2). Contextual influences were defined as influences that arise due to historic, sociocultural, institutional, economic or political factors; individual and group influences as
influences that arise from personal perception or influences of the social /peer environment and
vaccine /vaccination specific influences as influences directly related to the vaccine or
vaccination. Again the Working Group emphasized that Table A3.1 presented a very complex
matrix. Several Working Group members initially commented that while this “influencer” matrix
might work well in high income countries, they had concerns that important factors affecting
vaccine hesitancy in low income countries might not fit in well and that the model might hamper
thinking in determination of the roots of vaccine hesitancy in these settings. Table A3.1 was
modified and simplified into the Working Group Matrix (Table 3.1above) to address these
concerns. This Matrix is seen as especially potentially useful in selecting vaccine hesitancy
indicators and survey questions (Table 3.2 above). Later review of the Working Group Matrix in
terms of the determinants raised in the Working Group systematic review of the literature on
determinants (Section 4), review of other published review studies on determinants (Section4)
and the findings from the Immunization Managers Survey by the Working Group (Section 4) did
not raise any new determinants that could not be fitted into the Working Group Matrix and hence
the Working Group Matrix was accepted.
Figure A3.2. Systems Approach to Understanding Reasons for Vaccine Hesitancy
Table A3.1 A model to identify determinants of vaccine hesitancy
CONTEXTUAL
INFLUENCES
Influences
arising due
to historic,
sociocultural,
environment
al, health
system/instit
utional,
economic or
political
factors
a.Communication
and media
environment
Media and social
media can create
a negative or
positive vaccine
sentiment and
can provide a
platform for
lobbies and key
opinion leaders to
influence others;
social media
allows users to
freely voice
opinions and
experiences and it
can facilitate the
organization of
social networks
for or against
vaccines .
b. Influential
leaders,
gatekeepers and
anti- or provaccination
lobbies
Community
leaders and
influencers,
including religious
leaders in some
settings,
celebrities in
others, can all
have a significant
influence on
vaccine
acceptance or
hesitancy.
c.Historical
influences
Historic influences
such as the
negative experience
of the Trovan trial
in Nigeria can
undermine public
trust and influence
vaccine acceptance,
as it did for polio,
especially when
combined with
pressures of
influential leaders
and media. A
community’s
experience isn’t
necessarily limited
to vaccination but
may affect it.
d.Religion/culture/ge
nder/socio-economic
A few examples of the
interplay of
religious/cultural
influences include:
Some religious
leaders prohibit
vaccines
Some cultures do not
want men vaccinating
children
Some cultures value
boys over girls and
fathers don’t allow
children to be
vaccinated),
e. Politics/policies
(Mandates)
f.Geographic
barriers
g.Pharmaceutic
al industry
Vaccine mandates
can provoke vaccine
hesitancy not
necessarily because
of safety or other
concerns, but due to
resistance to the
notion of forced
vaccination
A population can
have general
confidence in a
vaccine and health
service, and be
motivated to receive
a vaccine but
hesitate as the
health center is too
far away or access is
difficult.
Industry may be
distrusted and
influence
vaccine
hesitancy when
perceived as
driven only by
financial
motives and not
in public health
interest; This
can extend to
distrust in
government
when perceived
that they are
also being
pushed by
industry and not
transparent.
INDIVIDUAL and
GROUP
INFLUENCES
Influences arising
from personal
perception of the
vaccine or
influences of the
social/peer
environment
a. Experience
with past
vaccination
Past negative or
positive
experience with
a particular
vaccination can
influence
hesitancy or
willingness to
vaccinate.
Knowledge of
someone who
suffered from a
VPD due to nonvaccination may
enhance vaccine
acceptance.
Personal
experience or
knowledge of
someone who
experienced an
AEFI can also
influence
hesitancy.
b.Beliefs, attitudes
about health and
prevention
Vaccine hesitancy
can result from 1)
beliefs that vaccine
preventable diseases
(VPD) are needed to
build immunity (and
that vaccines destroy
important natural
immunity) or 2)
beliefs that other
behaviors
(breastfeeding,
traditional/alternativ
e medicine or
naturopathy) are as
or more important
than vaccination to
maintain health and
prevent VPDs.
c.Knowledge/aware
ness
Decisions to
vaccinate or not are
influenced by a
number of the
factors addressed
here, including level
of knowledge and
awareness. Vaccine
acceptance or
hesitancy can be
affected by whether
an individual or
group has accurate
knowledge, a lack of
awareness due to no
information, or
misperceptions due
to misinformation.
Accurate knowledge
alone is not enough
to ensure vaccine
acceptance, and
misperceptions may
cause hesitancy, but
still result in vaccine
acceptance.
d. Health system and
providers-trust and
personal experience.
Trust or distrust in
government or
authorities in general,
can affect trust in
vaccines and
vaccination
programmes delivered
or mandated by the
government. Past
experiences that
influence hesitancy can
includes system
procedures that were
too long or complex, or
personal interactions
were difficult.
e. Risk/benefit (perceived,
heuristic)
Perceptions of risk as well as
perceptions of lack of risk can affect
vaccine acceptance. Complacency
sets in when the perception of
disease risk is low and little felt need
for vaccination. E.g. Patient’s or
caregiver’s perceptions of their own
or their children’s risk of the natural
disease or caregivers’ perceptions of
how serious or life threatening the
VPD is.
f. Immunisation as
a social norm vs.
not
needed/harmful
Vaccine acceptance
or hesitancy is
influenced by peer
group and social
norms
VACCINE/
VACCINATION
-specific
issues
Directly
related to
vaccine or
vaccination
a. Risk/ Benefit
(scientific
evidence)
Scientific
evidence of
risk/benefit and
history of safety
issues can
prompt
individuals to
hesitate, even
when safety
issues have
been clarified
and/or
addressed
e.g. suspension
of rotavirus
vaccine due to
intussusception;
Guillain-Barre
syndrome
following swine
flu vaccine
(1976) or
narcolepsy
(2011) following
(A)H1N1
vaccination;
milder, local
adverse events
can also
provoke
hesitancy.
b. Introduction of
a new vaccine or
new formulation
Individuals may
hesitate to accept
a new vaccine
when they feel it
has not been
used/tested for
long enough or
feel that the new
vaccine is not
needed, or do not
see the direct
impact of the
vaccine (e.g. HPV
vaccine preventing
cervical cancer).
Individuals may be
more willing (i.e.
not complacent)
to accept a new
vaccine if
perception of the
VPD risk is high.
c. Mode of
administrati
on
Mode of
administratio
n can
influence
vaccine
hesitancy for
different
reasons. E.g.
oral or nasal
administratio
ns are more
convenient
and may be
accepted by
those who
find
injections
fearful or
they do not
have
confidence in
the health
workers skills
or devices
used.
d. Design of
vaccination
program/Mo
de of
delivery
Delivery
mode can
affect vaccine
hesitancy in
multiple
ways. Some
parents may
not have
confidence in
a vaccinator
coming
house-tohouse; or a
campaign
approach
driven by the
government.
Alternatively
if a health
centre is too
far or the
hours are
inconvenient
e. Reliability
and/or source of
vaccine supply
Individuals may
hesitate if they do
not have
confidence in the
system’s ability to
provide vaccine(s)
or might not have
confidence in the
source of the
supply (e.g. if
produced in a
country/culture the
individual is
suspicious of) ;
health workers may
also be hesitant to
administer a
vaccine (especially
a new one) if they
do not have
confidence that the
supply will continue
as it affects their
clients trust in
them.
Caregivers may not
have confidence
that a needed
vaccine and or
health staff will be
at the health
facility if they go
there.
f. Vaccination
schedule
Although there may
be an appreciation
for the importance
of preventing
individual vaccine
preventable
diseases, there may
be reluctance to
comply with the
recommended
schedule (e.g.
multiple vaccines or
age of vaccination).
Vaccination
schedules have
some flexibility that
may allow for slight
adjustment to meet
individual needs
and preferences.
While this may
alleviate hesitancy
issues,
accommodating
individual demands
are not feasible at
a population level.
g. Costs
An individual
may have
confidence in a
vaccine’s safety
and the system
that delivers it,
be motivated to
vaccinate, but
not be able to
afford the
vaccine or the
costs associated
with getting
themselves and
their child(ren)
to the
immunization
point.
Alternatively,
the value of the
vaccine might
be diminished if
provided for
free.
h. Role of
healthcare
professionals
Health care
professionals
(HCP)are important
role models for their
patients; if HCPs
hesitate for any
reason (e.g. due to
lack of confidence in
a vaccine’s safety or
need) it can
influence their
clients’ willingness
to vaccinate
Another model reviewed by the Working Group was the complex conceptual model from
WHO EURO (Figure A3.3) with factors arranged into opportunity, ability and motivational
categories with further breakdown into subcategories for each was also examined.
Figure A3.3 A Conceptual Model for Determining Use, Under-Use and Non-Use of Vaccination
services. WHO EURO
This model forcefully emphasized the complexity of vaccine hesitancy and the many potentially
inter acting factors. While these categories were seen as easier to grasp than the contextural
influencer terminology (Figure A3.2 and Table A3.1), this was such a complex model that
several Working Group members noted that it would be more useful for research than for
application in the field. Thus inclusion of these categories with the complexity they implied in
the definition of vaccine hesitancy did not seem useful. Finding a vaccine hesitancy workable
model that used easily understood terminology, applicable in both HIC and LIC settings and yet
illustrating that factor groupings might overlap and aggravate vaccine hesitancy tendencies was
the goal. These more complex matrixes however, were useful in the work on the systematic
literature review of vaccine hesitancy including examination of potential strategies and
interventions.
The Confidence, Complacency, and Convenience Model: The final model examined was a
more simplified conceptual framework also based upon work done in WHO EURO. In this
model, the terminology for the factor groups is: confidence, complacency and convenience with
overlap not only possible but in some settings probable (Figure A3.4).
Figure A3.4. The 3 C’s of Vaccine Hesitancy: Confidence, Complacency and Convenience
Trust in vaccines, in the
system that delivers them,
and in the policy-makers
who decide which
vaccines are needed and
when.
Complacency
Confidence
Perceived risks of vaccinepreventable diseases are low;
vaccination is not deemed a
necessary preventive action. Other
life /health responsibilities seen as
more important at that point in time
Convenience
Extent to which physical
availability, affordability,
willingness-to-pay for,
geographical accessibility,
ability to understand (language
and health literacy) and appeal
of immunization services
affects uptake.
In further discussion the Working Group noted that understanding how barriers to vaccine uptake
belonging to one or many of the 3 Cs could be important in the design of activities and strategies
that could have a positive impact on vaccine hesitancy. These issues require different types of
interventions (convenience issues call for activities and strategies such as reducing costs or
enhancing geographic access to vaccination services, while confidence issues might need
education, counselling support etc.). The Working Group incorporated this very simplified 3 C’s
determinants concept into the definition of vaccine hesitancy.
In conclusion the Working Group judged that the 3”C” model was the easiest to grasp and a
simplified version of the Working Group Matrix was developed. (See main text)
Appendix for Section 4
Appendix A4.1: Systematic review on vaccine hesitancy
Published on WHO SAGE website:
http://www.who.int/immunization/sage/meetings/2013/april/2_Systematiclit_Review.pdf?ua=1, accessed 03.10.2014
Appendix A4.2: Mapping vaccine hesitancy- Country specific characteristics of a global
phenomenon
Mapping vaccine hesitancy: Country specific characteristics of a global phenomenon
Authors: Eve Dubé PhDa,b,c, Dominique Gagnon MSca, Emily Nickels MSPHd, Stanley Jeram
MDd, Melanie Schuster MDd,
Institutional Affiliations
a. Institut national de santé publique du Québec (INSPQ), Québec (Québec), G1E 7G9,
Canada
b. Centre de recherche du CHU de Québec, Québec (Québec), G1V 4G2, Canada
c. Université Laval, Québec (Québec), G1V 0A6, Canada
d. World Health Organization, 20 Ave Appia, CH 1211, Geneva 27, Switzerland
Abstract
Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability and
quality of vaccine service. Vaccine hesitancy is complex and context specific varying across
time, place and vaccines. It includes factors such as complacency, convenience and confidence.
Several hypotheses attempt to explain why acceptance of vaccines is decreasing. The Strategic
Advisory Group of Experts (SAGE) on Immunization recognized the global importance of
vaccine hesitancy and recommended that an interview study be conducted with immunization
managers (IM) to better understand the variety of vaccine hesitancy challenges existing on the
ground. Interviews with 13 selected IMS were conducted between September and December
2013. Challenges around vaccine hesitancy were found. The term was not consistently defined
and many IMs interpreted it as vaccine refusal. Although vaccine hesitancy existed in all 13
countries surveyed, some IMs considered the impact of vaccine hesitancy on immunization
programs as a minor problem. The causes of vaccine hesitancy were variable and contextspecific suggesting the need to strengthen the capacity of countries to identify context-specific
factors and to develop adapted strategies to address them.
Keywords: Vaccine hesitancy, immunization, determinants, vaccination, interviews.
immunization managers
Mapping vaccine hesitancy- Country specific characteristics of a global phenomenon
1. Introduction
Vaccine hesitancy refers to delay in acceptance or refusal of vaccines where uptake of a
vaccine or the immunization program in a community is lower than would be expected in the
context of information provided and the services available. Vaccine hesitancy is complex and
context specific varying across time, place, and vaccines. It recognizes that factors such as
complacency, convenience, as well as confidence in vaccines(s) or immunization programs
may all contribute to the delay or refusal of one, some or almost all vaccines [1].
Many factors influence the decision to demand, accept, delay or refuse immunization. Several
hypotheses have been put forward to try to explain why acceptance of vaccines is decreasing.
In high income countries, one factor maybe decreased visibility or absence of vaccine
preventable diseases leading to questioning of the necessity of vaccination and a waning of
trust in vaccines. Discussions in the general population in HIC about the utility and
practicality of vaccines have increased [2-5]. However, in low- and middle-income countries
where vaccine-preventable diseases still pose a more imminent threat to public health,
absence or decreased in their visibility does not explain the decrease in vaccine acceptance
[6-9]. This suggests different underlying determinants maybe contributing to hesitancy to
receive vaccination [3].
The Strategic Advisory Group of Experts (SAGE) on Immunization recognized the global
importance of vaccine hesitancy as an emerging issue. At the November 2011 meeting,
SAGE welcomed the decision to create a working group to address this issue. The SAGE
Working Group on Vaccine Hesitancy was established in March 2012 with the mandate to
prepare for a SAGE review and advice on how to address vaccine hesitancy and its
determinants [10]. In April 2013, following the presentation of the Working Group’s interim
findings, SAGE recommended that interviews be conducted with immunization managers in
order to better understand the variety of challenges existing on the ground [1, 3].
This paper reports the results of the interviews conducted with selected immunization
managers from different regions between September and December 2013. It is a first attempt
to broadly assess the status of vaccine hesitancy on a global level from the perspective of
different national immunization managers.
2. Methods
The SAGE Working Group developed a telephone-based interview guide designed to
qualitatively capture unanticipated responses whilst assessing known determinants of vaccine
hesitancy. Data were collected using semi-structured interviews, the standard method to
explore complex phenomena [11, 12].
10
In order to create a representative sample of countries with a broad range of socio-economic
contexts and population sizes over all regions, purposive sampling technique was used.
Criteria for selection included:
i. Representation from all six WHO Regions orchestrated by the WHO regional
offices, Africa (AFR), Europe (EUR), Eastern Mediterranea (EMR), Americas
(AMR), South-East Asia (SEAR), and Western Pacific (WPR);
ii. Representation from the three economic categories recognized by the World Bank:
low, middle and high income countries (respectively, LIC, MIC, and HIC) [13].
iii. To be eligible for the interview, the national immunization manager had to be
experienced and responsive.
In consultation with WHO immunization regional advisors, 15 countries were selected that
together met the range of criteria. Key staff from WHO regional offices contacted
immunization managers from each of the selected countries. In order to improve response
rate, an introductory email was sent from WHO to the immunization managers outlining the
request and the importance of the data collection. Countries who had not responded to the
initial email within one month were sent a reminder email from WHO.
The semi-structured interview was conducted by two interviewers from WHO. To ensure
consistency, the interviewers remained the same throughout the study. Interviews were
conducted in English, Spanish, or French.
The interviews were recorded and summarized by the interviewer. Interview transcription
was sent back to all immunization managers for approval; if needed, changes were made to
more accurately reflect the country’s situation. A structured electronic data extraction form
was developed with predefined data fields for extracting consistent data. For all interviews,
data were extracted and entered by two independent researchers at WHO and Institut
National de Santé Publique du Québec, Canada. A third independent senior researcher
checked for accuracy and completeness of the two datasets. In order to ensure consistency,
the two datasets were combined and discrepancies were highlighted. In case of discrepancies,
reasons were assessed by the senior researcher. These were then discussed by the research
team until a decision about relevance was reached by consensus. If there was no agreement,
the senior researcher adjudicated to make a final decision. Data analysis was conducted by
the researchers from Institut National de Santé Publique du Québec with thorough experience
in the field of qualitative research. Data were analyzed by question and mapped against a
matrix of determinants developed by the Vaccine Hesitancy Working Group [14].
3. Results
Interviews were conducted with 13 immunization managers from the six different WHO
regions: 2 from the AFR (Congo, Zimbabwe), 1 from the SEAR (India), 2 from the EMR
(Saudi Arabia, Yemen), 3 from the EUR (Armenia, Belgium, Montenegro), 4 from the WPR
(Japan, Lao PDR, Malaysia, The Republic of the Philippines), 1 from the AMR (Panama) and
11
represented mostly low and middle income countries (n=11). Interviews lasted an average 30
minutes.
3.1. Definition of vaccine hesitancy
Four immunization managers explicitly defined their understanding of vaccine hesitancy.
One defined hesitancy as “those persons resisting to get vaccinated due to various reasons”
and another mentioned “someone who does not believe vaccines are working and are
effective and that vaccines are not necessary”. A third indicated that hesitancy was twofold
and included 1) “parents who would not allow immunization of their child” and 2) “policy
makers who hesitate to introduce a vaccine especially in regard to new vaccines vs other
existing public health interventions”. The fourth defined vaccine hesitancy as “an issue that
should be addressed when reaching 90% vaccination coverage”. Although other
immunization managers’ views regarding vaccine hesitancy were less explicit, most (n=9)
associated vaccine hesitancy with parental refusal of one or more vaccines. Vaccination
delays were not included in vaccine hesitancy by immunization managers, except in one
country, where the immunization managers stated: “There is not a problem with undervaccinated or unimmunized. There are issues with timely vaccination – with following the
schedule. Parents are delaying the vaccines”. Table 1 summarizes immunization managers’
opinions regarding vaccine hesitancy in their country.
3.2. Impact of vaccine hesitancy on the country’s’ immunization program
At the time of the interview, all except one immunization manager had heard reports of
people hesitating to accept one or all vaccines in their country. In the country where no
reports had been heard, the actual problem reported was vaccine refusal due to religious
beliefs, not hesitancy). In another country, the immunization manager had not heard of any
reports of vaccine hesitancy, but acknowledged that a small proportion of the whole
population had some concerns regarding vaccine safety and could be considered as vaccinehesitant.
In several countries, immunization managers reported current or past issues of lack of
acceptability related to one specific vaccine or to specific combinations of vaccines. These
vaccines included: tetanus toxoid vaccine (TT); combined vaccine against diphtheria, tetanus,
and pertussis (DTaP); combined vaccine against measles, mumps and rubella (MMR) or
measles vaccine; oral polio vaccine (OPV); vaccine against human papilloma virus (HPV);
influenza vaccine; vaccine against tuberculosis (BCG) and combined vaccine against
diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (pentavalent vaccine).
Even if with reports of vaccine hesitancy in their country, 11 out of 13 immunization
managers did not consider vaccine hesitancy to be common and felt it did not have a
significant impact on the uptake in the routine immunization programs. Immunization
managers from two countries indicated that mass immunization campaigns, and not routine
12
immunization programs, were affected by vaccine hesitancy. Two immunization managers
indicated that vaccine hesitancy was an important issue in their country.
When immunization managers were asked about the percentage of non- and under-vaccinated
individuals in their country due to lack of confidence, eight of 13 provided estimates ranging
from less than 1% to 30% (Table 1). Five did not answer. Only one immunization manager
cited the two seasonal uptake estimates for OPV to support the estimate while three others
either had planned to quantify the extent of the problem in their countries or had recently
completed a survey.
Three immunization managers reported issues of complacency in their countries. In contrast,
four other immunization managers stated that there were no issues of complacency because
immunization was perceived as a priority by most of the population. Another immunization
manager stated that there were complacency issues among a particular indigenous group who
had refused vaccination because vaccination activities coincided with a cultural event. The
other immunization managers did not respond to this question.
Seven of the 13 immunization managers perceived convenience/access issues to be important.
Convenience issues were associated with sub-populations not using the health services
provided (e.g. illegal settlers) or hard-to-reach population (e.g. conflict areas and refugee
camps or remote communities). In one country, more than 25% of the population has no
access to health services. In this country, access is challenging for immigrants, refugees,
nomad populations, those living in remote areas and women (mainly because of the socionorms that they need somebody to travel with them if they need to get healthcare). In another
country, convenience was not major issue, because barriers to access such as language or
culture are handled and addressed locally. The only sub-group that was said to potentially
experience convenience issues were migrant populations.
3.3.
Determinants of vaccine hesitancy using the Working Group matrix
Figure 1 summarizes immunization managers’ opinions for their country regarding the
determinants of vaccine hesitancy in the matrix developed by the Working Group.
3.3.1. Contextual influence
Religious beliefs were often associated with vaccine hesitancy by nine of 13 immunization
managers. Several were able to specifically identify religious groups in their country that
were known to be opposed to all vaccines while others discussed “religious reasons” without
specifically identifying a religion or a group. Religious beliefs were mostly linked to refusal
of all vaccines, except in one country, where there were specific problems of acceptance of
the HPV vaccine among those who were Catholic. Other groups associated with vaccine
hesitancy were ethnic or indigenous groups, people of higher socioeconomic status and
people living in urban areas. One immunization manager indicated that the older generation
13
was more hesitant than the younger generation and another, that women were more hesitant
than men.
Six of 13 immunization managers mentioned the role of influential leaders in increasing
vaccine hesitancy among the population. These leaders were associated with anti-vaccination
groups, religious groups or health professional groups.
Five of 13 immunization managers identified causes of vaccine hesitancy linked to the
“communication and media environment”. Two immunization managers spoke broadly about
“rumors and misconceptions” regarding vaccination circulating in their country and three
directly identified negative information conveyed in the mass media (television and internet)
as causes of vaccine hesitancy.
Six immunization managers identified the involvement of geographic barriers in reducing
access to vaccination services, but the association with vaccine hesitancy was not clear.
In one country, political conflicts and instability leading to poverty, internal population
displacements and insecurity, could partially explain vaccine hesitancy. More than one
quarter of the population has no access to health services, as noted above. Access to services
was stated to be particularly difficult for women.
Finally, in one country, vaccine hesitancy was mostly clustered around illegal settlers or
immigrants without an official status. These individuals hesitate to use health services
because of fear of being reported to the police, even though the Expanded Programme on
Immunization (EPI) offers immunization with permission from the government.
3.3.2. Individual and group influences
Three main determinants of vaccine hesitancy pertaining to individual and group influences
were identified. First, seven of 13 immunization managers identified risk perceptions as
associated with vaccine hesitancy. This included concerns regarding vaccine safety, lack of
perceived benefits of vaccination and lack of understanding the burden of vaccinepreventable diseases.
Second, seven immunization managers identified issues to the population’s trust in the health
system and health providers. One noted that how people were treated in the health services
could have a negative impact on whether they returned while others highlighted the
influential role that health care workers have on vaccine acceptance among the population. In
one country, women prefer to receive care by female providers, which are scarce in that
country and could at least partially explain the lack of vaccination among women.
Finally, four immunization managers identified that lack of knowledge (or misinformation) in
the population regarding vaccination was a contributing factor to vaccine hesitancy. One
immunization managers specified that lack of knowledge about vaccination among health
professionals was linked to vaccine hesitancy.
14
3.3.3. Vaccine and vaccination specific issues
Risk of adverse events following immunization was identified by three immunization
managers as contributing to vaccine hesitancy.
Three immunization managers noted that the design of the vaccination program contributed
to vaccine hesitancy. In two countries, vaccine hesitancy was related to mass vaccination
programs and not routine immunization programs. In the other country, religious members
were refusing to bring their children to the hospital or health centers for immunization but
agreed to have them immunized if offered at home.
In one country, reliability of the vaccine supply was also noted as a difficulty; because
vaccines were out of stock, vaccination series were not completed. In another one, the
provenance of the vaccines, was linked to vaccine hesitancy. There was distrust in vaccines
produced in developing countries (India and Indonesia) caused vaccine hesitancy among
health care workers who would prefer to use vaccines produced in Europe. In two countries,
immunization managers noted that there were concerns among the Muslim population due to
suspected use of porcine components in vaccines. Finally, introduction of new vaccines or
new indications was perceived (more or less explicitly) as contributing to vaccine hesitancy
in four countries. In one country, the introduction of new and costly vaccines was seen as
triggering vaccine hesitancy.
4. Discussion
This study revealed a number of challenges concerning vaccine hesitancy including the
presence of discrepancies in how vaccine hesitancy was understood by immunization
managers. It was not consistently defined and several immunization managers interpreted it,
explicitly or implicitly, as including or limited only to vaccine refusal. Several noted stock
outs as a cause. Yet the definition developed by the Working Group specifies that vaccine
hesitancy refers to delay in acceptance or refusal of vaccines despite availability and quality
of vaccine service. This indicates that the proposed definition, while broad and inclusive, will
need to be promoted among immunization managers in the field if hesitancy is to be
comparably assessed. A common understanding of what falls under the umbrella of vaccine
hesitancy is essential in order to measure the scope of vaccine hesitancy, to look at potential
causes, to identify differences between countries and sub-populations, and to monitor the
changes over time.
Some immunization managers considered the impact of vaccine hesitancy on immunization
programs as a minor problem possibly due to the lack of understanding of the term. The
findings when lack of vaccine confidence was queried well illustrate the problem. The
immunization managers all struggled (and 5 of 13 did not answer) when asked to provide an
estimate of the percentage of non- and under-vaccinated individuals in their countries in
whom lack of confidence was an issue. This could be related to difficulty in quantifying such
15
a variable or to a lack of understanding of what is considered in the terms “lack of
confidence” and even term vaccine hesitancy. This further highlights the need for common
understanding of terminology.
While some immunization managers considered the impact of vaccine hesitancy on
immunization programs as a minor problem in their country, others saw it as more serious.
Although some immunization managers associated vaccine hesitancy to particular religious
or ethnic groups, most agreed that vaccine hesitancy is not exclusively clustered to specific
communities, and exists across all socioeconomic strata of the population. Some
immunization managers often associated it with highly educated individuals. This is in
agreement with previous studies conducted in different settings that have shown that noncompliant individuals appear to be well-informed individuals who have considerable interest
in health-related issues and actively seek information [15, 16]. Three IMs emphasized that
health professionals could be vaccine-hesitant themselves. This is of particular concern as
health professionals’ knowledge and attitudes about vaccines have previously been shown to
be an important determinant of their own vaccine uptake, their intention to recommend the
vaccine to their patients, and the vaccine uptake of their patients [17-20].
The sense that vaccine hesitancy is not uniform in the country is also a challenge.
Immunization managers may need to not only carry out a country assessment of hesitancy,
but also a sub-national and even a district level assessment, to fully understand the extent of
hesitancy within a country. This will be especially key when planning for supplementary
immunization activities, surveys or specific campaigns to catch up the non- or undervaccinated, with vaccine-hesitant being one possible choice of target groups.
The immunization managers surveyed noted variable and context-specific causes of vaccine
hesitancy. Confidence, complacency and /or confidence issues were all raised. Overall, the
findings fit well within the matrix of determinants of vaccine hesitancy developed by the
SAGE Working Group. All issues raised by the countries were reflected within the matrix
and no additional determinants were identified. Among frequent determinants raised by
immunization managers were concerns regarding vaccine safety sometimes due to
scientifically proven adverse events after immunization while others were triggered by
rumors, misconceptions or negative stories conveyed in the media. A more frequently named
determinant of vaccine hesitancy was religious beliefs and the influence of religious leaders.
Refusal of some or all vaccines among religious communities has been well-documented [21,
22]. Opposition to vaccination based on religious motives is not a new phenomenon and can
be explained, at least partially, by the idea that vaccination is not in line with religious
considerations of the “origin of illness, the need for preventive action and the search for a
cure” [21]. The influence of communication and media, the lack of knowledge or education,
and the mode of vaccine delivery (i.e. mass vaccination campaigns) were other determinants
of vaccine hesitancy identified by immunization managers. In LMICs, geographic barriers to
vaccination services, political conflicts and instability or illegal immigration were linked with
vaccine hesitancy.
16
The findings from this survey, further emphasize the usefulness of the new concept “vaccine
hesitancy” if we are to better understand determinants of vaccine acceptance. It represents a
shift from the dichotomous perspective “anti- versus pro-vaccine” to an approach picturing
vaccination behaviour on a continuum ranging from active demand for vaccines to complete
refusal of all vaccines [23]. This study is the first to report immunization managers
understanding of this term and emphasizes the need for further education about this term. The
results have provided useful insights on the actual situation in different countries, showing
the variability in manifestation of vaccine hesitancy. However, the results should be
considered in light of some limitations. The countries were selected by WHO in order to
represent a diversity of regions and situations, but it was difficult to obtain participation of
some countries. Two IMs could not participate for different reasons. Most interviews were
conducted in English and this may have been challenging for non-English speakers, resulting
in information bias. Interviews were loosely conducted and some questions were not asked to
every IM. As with all qualitative study, desirability bias cannot be excluded and findings are
not generalizable to all countries. It is important to note that the country-specific situation in
regard to vaccine hesitancy was reported by a single IM, often based on his/her own opinions
and estimations, and it is thus very possible that different views could have been expressed if
we had interviewed another informant in the same country. That being said, the IM is
generally very well-informed on issues surrounding vaccination.
To conclude, because the success of immunization programs relies mainly on population and
health professionals confidence, it is particularly vulnerable to controversy [24].
Understanding the specific concerns of the various groups of vaccine-hesitant individuals,
including health professionals is important as hesitancy may result in vaccination delays or
refusals. Vaccine hesitancy is an individual behavior, but is also the result of broader
influences and should always be looked at in the historical, political and socio-cultural
context in which vaccination occurs. Many predictors of vaccine acceptance have been
identified at the individual level, and include knowledge, attitudes or perceived risks. This
study suggests that an individual’s choice to use vaccination services is far more complex
involving emotional, sociocultural, spiritual, political and structural factors as much as
cognitive factors. There is a need to strengthen the capacity of countries to identify contextspecific roots of vaccine hesitancy and to develop adapted strategies to address them.
Conflict of interest statement: Nothing to declare.
Acknowledgements
We want to thank the participating national immunization managers as well as WHO staff at
the regional and national offices for orchestrating the interviews. We also thank the members
of the SAGE Working Group on vaccine hesitancy for their contribution in the design of the
study and interpretation of the results: Mohuya Chaudhuri, Philippe Duclos, Bruce Gellin,
Susan Goldstein, Juhani Eskola, Heidi Larson, Xiaofeng Liang, Noni MacDonald, Mahamane
Laouli Manzo, Arthur Reingold, Dilian Francisca Toro Torres, Kinzang Tshering, Yuqing
Zhou. This study was sponsored by the World Health Organization.
17
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18
Table 1. Summary of IMs’ opinions on vaccine hesitancy
Countries
Country A
IM perspective on vaccine hesitancy in their country
Vaccine hesitancy is mostly associated with mass vaccination campaigns,
especially against polio. It is mostly clustered in large cities and associated with
particular religious groups. Routine immunization programs are not affected by
vaccine hesitancy and access is the main issue.
•
Country B
Vaccine hesitancy is not considered a problem in the country. Instead, there is
vaccine refusal, which is associated with religious groups and higher
socioeconomic status. However, vaccine refusal is also not considered a major
problem.
•
Country C
% of un- or under-vaccinated in whom lack of confidence was a
factor: unanswered.
% of un- or under-vaccinated in whom lack of confidence was a
factor: 10% (estimated)
Vaccine hesitancy is not considered a major issue in the country. However, there
is a small proportion of the whole population who has concerns about the safety
of vaccines and could be categorized as vaccine-hesitant. This is mostly related to
the new and costly vaccines, such as the pentavalent vaccine and is mostly seen in
the well-educated population group. There are no issues of complacency or
convenience (except for migrant populations). Vaccine hesitancy is not
considered to have a significant impact on overall coverage rates.
•
% of un- or under-vaccinated in whom lack of confidence was a
factor: < 5% (estimated)
Vaccine hesitancy is not an issue in the country. Vaccine hesitancy is limited to
illegal settlers.
Country D
Country E
•
Although political conflict and instability negatively affect overall access to
health services, vaccine hesitancy is not a major issue in the country. Some
negative rumors about vaccination have circulated in selected regions and groups
of people. Access to immunization services is challenging for women and
nomads.
•
19
% of un- or under-vaccinated in whom lack of confidence was a
factor: < 1% (estimated)
% of un- or under-vaccinated in whom lack of confidence was a
factor: unanswered
Country F
Vaccine hesitancy is not a major issue in the country and most children are fully
immunized by the age of two. Vaccine hesitancy is mainly associated with
medical academics and health care workers who don’t believe vaccines are safe
and effective (especially combination vaccines and vaccines produced in
developing countries). Additionally, there have been issues with religious groups
being advised against vaccines because it is forbidden by their religion as well as
concerns regarding the safety of combination vaccines.
•
Country G
In the country, vaccine hesitancy leading to vaccine refusal is not very frequent
and is rather localized. Vaccine hesitancy issues have come up in particular
groups such as anthroposophist schools, the orthodox Jewish community and
Roma societies. In Belgium, complacency and access to certain communities are
bigger issues than hesitancy.
•
Country H
20
% of un- or under-vaccinated in whom lack of confidence was a
factor: unknown
In the country, there are two major groups hesitant to get vaccinated: 1) a small
minority of religious groups who do not believe in the benefit of vaccines due to
religious or philosophical reasons and 2) the general public concerned by adverse
events following immunization (AEFI). Vaccine hesitancy is associated with
specific vaccines being in “the focus of attention” (such as HPV or OPV). Media
reports of rare adverse events make parents hesitant to vaccinate their children,
resulting in decreased uptake. While access and complacency are not important
issues, it is speculated that vaccine hesitancy could explain up to 30% of the
decrease observed in OPV vaccine coverage (prior to IPV introduction).
•
Country J
% of un- or under-vaccinated in whom lack of confidence was a
factor: unanswered
Vaccine hesitancy exists but is not a major issue in the country. It is not linked to
particular groups or geographic areas. Vaccine hesitancy is associated with a lack
of perceived benefit of vaccination due to low prevalence of vaccine-preventable
disease in the country. There are also concerns regarding vaccine safety and the
negative influence of “Internet stories”.
•
Country I
% of un- or under-vaccinated in whom lack of confidence was a
factor: unknown
% of un- or under-vaccinated in whom lack of confidence was a
factor: 30% (OPV only, measured)
Vaccine hesitancy is an important issue in the country. Vaccine hesitancy is
associated with particular ethnic minorities (ethnic Hmong) and remote
communities, with a particular focus on the education level of the local
population in remote communities. Vaccine hesitancy is associated with lack of
perceived benefits of immunization and negative beliefs based on myths (such as
vaccination of women leading to infertility).
•
Country K
Vaccine hesitancy exists in the country, but is rather small. Vaccine hesitancy is
mostly associated with people of high socio-economic status living in urban areas
who have concerns regarding vaccine safety (especially thiomersal containing
vaccines). Concerns regarding porcine components in vaccines by Muslim
populations also contribute to vaccine hesitancy in the country.
•
Country L
% of un- or under-vaccinated in whom lack of confidence was a
factor: 20% (estimated), 8% refused vaccine (measured)
Vaccine hesitancy is not an important issue in the country and the immunization
program has a positive image. However, vaccine hesitancy did occur in particular
situations and populations. For example, vaccine hesitancy originated from the
Catholic Church when HPV vaccine was introduced, and from healthcare
professionals when influenza vaccine and TDaP were recommended to be
administered to pregnant women. Vaccine hesitancy also occurred among
indigenous groups. Additionally, there are vaccine refusals among indigenous
groups when vaccination week coincides with cultural events. Geographic
barriers may limit the percent vaccinated in some remote areas, but is not linked
with vaccine hesitancy. There are no anti-vaccine groups in the country and there
is not much vaccine refusal.
•
21
% of un- or under-vaccinated in whom lack of confidence was a
factor: <5% (estimated)
Vaccine hesitancy is mostly related to Tetanus Toxoid (TT) mass vaccination
campaigns. As a result of vaccine hesitancy due to concerns with vaccine safety,
up to 20% of eligible population is un- or under-vaccinated. Serious AEFIinflammation at the site of injection and Catholic pro-life groups stating that TT
vaccination was resulting in abortion or infertility have contributed to vaccine
hesitancy regarding TT vaccination. Routine vaccination programs are not
affected by vaccine hesitancy.
•
Country M
% of un- or under-vaccinated in whom lack of confidence was a
factor: 30% (estimated, % of Hmong tribe population)
% of un- or under-vaccinated in whom lack of confidence was a
factor: unknown
Figure 1. IMs’ opinions regarding determinants of Vaccine Hesitancy*
SAGE WG Vaccine Hesitancy Model
CONTEXTUAL
INFLUENCES
Religion/ culture/
gender/ socioeconomic
Influential leaders and
anti- or pro-vaccination
lobbies
Communication and
media environment
Geographic barriers
INDIVIDUAL AND
GROUP
INFLUENCES
VACCINE AND
VACCINATION
SPECIFIC ISSUES
Risk/ benefit
(perceived, heuristic)
Risk/ Benefit
(scientific evidence)
Health system and
providers - trust and
personal experience
Design of vaccination
program/ Mode of
delivery
Knowledge/ awareness
Reliability and/or source
of vaccine supply
Experience with past vaccination
Beliefs, attitudes about health and
prevention
Introduction of a new
vaccine or new formulation
Immunisation as a social norm vs.
not needed/ harmful
Costs
Politics/ policies (Mandates)
Vaccination schedule
Historical influences
Mode of administration
Pharmaceutical industry
Role of healthcare professionals
*Larger font size represents greater number of mentions while determinants under the line were not mentioned by the IMs.
22
Appendix for Section 5
Appendix A5.1: Pilot Test of Vaccine Confidence Indicators 2012
Pilot Test of Vaccine Confidence Indicators 2012
GAVP Strategic Objective 2
Background
Vaccine hesitancy is not a new phenomenon, although more attention has been paid to it in
recent years. Vaccine hesitancy is an emerging term in the discourse on determinants of
vaccine acceptance where uptake of a vaccine or immunization program in a community is
lower than would be expected in the context of information given and services available.
Vaccine hesitancy recognizes that issues of complacency, convenience and/ or confidence in
vaccine(s) or immunization programs may all contribute to the delay or refusal of one, some
or almost all vaccines. These factors which influence vaccine acceptance vary by setting and
responses need to be locally assessed.
In 2012, the WHO Strategic Advisory Group of Experts on Immunization (SAGE)
established a Working Group to address the issue of vaccine hesitancy which defined vaccine
hesitancy and its scope and identified drivers of vaccine hesitancy.
In light of the Decade of Vaccines Global Vaccine Action Plan, the working group was asked
to develop and pilot test one or several indicator(s) of vaccine confidence that could be used
to monitor the issue on a global and on a national level. The group was asked to pilot test
these two indicators over a broad range of regions in countries with representing all levels of
income to assess response, comparability and feasibility.
Methods
Sampling frame
The WHO PAHO and the EUR region volunteered to pilot test the questions related to the
indicators in their 2012 UNICEF/WHO Joint Reporting Form (JRF). The JRF was sent to the
countries in December 2012 and January 2013. The countries were asked to return the
completed forms by 15. April 2013. In addition self-administered questionnaires were
personally distributed at the Intercountry Support Team South & East and Central Africa
immunization managers' meeting in Q1 2013 to selected EPI managers. The selfadministered questionnaire allowed immunization managers to comment on the two
indicators.
Indicators and definition
The questions related to the indicators to assess vaccine confidence were translated in 4
WHO languages, French, Russian, Spanish and English. The questions were accompanied by
the definition of vaccine confidence.
23
Definition
Vaccination confidence is one of a number of factors that affect individual and populationlevel willingness to accept a vaccine. It means having confidence in the safety and efficacy of
a vaccine, having confidence in the reliability and competence of the health services and
health professionals who deliver and administer the vaccine, and having trust in the
motivations of the policy-makers who decide which vaccines are needed and when.
If vaccine coverage is understood as being determined by a combination of supply and
demand factors, confidence is primarily a demand factor, although it can be influenced by
supply factors such as ease or difficulty in accessing services, competence of the vaccinator
and reliability of the vaccine supply. It can also be influenced by factors outside the health
system.
Indicator 1: % of countries that have assessed (or measured) the level of confidence in
vaccination at subnational level.
Question 1:
Has there been some assessment (or measurement) of the level of confidence in vaccination
at subnational level in the past?
Question 2:
If yes, please specify the type and the year the assessment has been done.
Indicator 2: % of un- and under-vaccinated in whom lack of confidence was a factor
that influenced their decision.
Question 1:
What is the % of un- and under-vaccinated in whom lack of confidence was a factor that
influenced their decision (this applies to all vaccines)?
Question 2:
Was this % measured or estimated?
Question 3:
Any comments or specific issue?
Classification
We classified the countries by level of income using the World Bank’s main criterion for
classifying economies, the gross national income (GNI) per capita.
Data collection and analysis
Data were collected by the respective regional offices, submitted to WHO HQ and analyzed
using Microsoft Excel and Stata 11.0.
Inclusion and Exclusion criteria
24
Inclusion criteria
• Recognized member state of WHO PAHO, EUR or AFR region
Exclusion criteria
• No indication of country
Results
Response rate:
The pilot test was conducted in three WHO regions: PAHO Member States supports the 35
countries in the Americas. WHO EURO supports the 53 Member States in the European
Region. Until 05.07.2013 not all countries had returned the completed JRF. In the EUR
region 48/53 countries (91%) provided a JRF for 2012. In the PAHO region, all 35 countries
(100%) provided a JRF for 2012.
Countries which did not provide a JRF were: The Former Yugoslav Republic of Macedonia,
Turkey, Austria, Finland and Monaco.
In AFRO, 14 national immunization managers were asked to complete the questionnaire. Of
these 11 provided the questionnaire which met the criteria to be included in the analysis.
Indicator 1:
Indicator 1 assessed whether a measurement of vaccine confidence had been done in
countries at a subnational level in the past. Of the countries which submitted a JRF or a
questionnaire, 17% in the European region had done a measurement, 20% in the Americas
and 27% of the participating African countries. (Table 1)
For complete list of countries and countries by indicator see ANNEX.
Table 1. Number of countries reporting an assessment (or measurement) of the level of
confidence in vaccination at subnational level
Region
EUR
Numbe
r
PAHO
Percenta
ge
Numbe
r
EUR and PAHO
Percenta
ge
Number
Percenta
ge
AFR
Numbe
r
Percentage
Assessment
n= 8
17%
n=7
20%
n=15
18%
n=3
27%
No
assessment
n=17
35%
n=24
69%
n=41
49%
n=8
73%
Question not
completed
n=23
48%
n=4
11%
n=27
33%
n=0
0%
Total
n=48
100%
n=35
100%
n=83
100%
n=11
100%
25
Of all participating countries, 19% (n=18) had assessed or measured the level of confidence
on a subnational level. (Figure 1)
Figure 1. Assessment of vaccine confidence of all participating countries
Indicator 1- assessment (or measurement) of the level of
confidence in vaccination at subnational level
assessment
no assessment
question not completed
19%
29% (n=18)
(n=27)
52%
(n=49)
Countries were asked to provide specific information on the type of assessment and the year
this assessment was done (Table 2).
Table 2. Type of assessment by year
Country
Type of assessment
Year of
assessment
Brazil
Rapid monitoring of vaccination provided information to explain the
reasons for non-vaccination or for abandoning the recommended
vaccination schedule.
No year
indicated
Chile
Conducted a small study, requested by the Ministry of Finance in 2012,
study focused on the perception of the National Immunization Program.
2012
Cuba
Not specified
2012
Dominican
Republic
Not specified
2012
Guatemala
Random Survey (1164 mothers / guardians) house to house. May 2011
2011
Jamaica
Evaluation of the Immunization Program in 2003; user survey
2003
Mexico
National Survey of Health and Nutrition 2006
2006
Belgium
Vaccination coverage study of infants (18-24 months of age) and
adolescents in Flanders, 2012.
2012
Czech
Republic
Administrative control
2011
26
Germany
Representative survey targeting parents of children aged 0-13 years
2010
Iceland
Survey among parents
2010
Italy
1.) Survey on communicative and organizational aspects of vaccination
campaign against HPV and acceptance of the vaccination in the Italian
Regions and proposal for a technical document for future campaigns
(VALORE), report not yet available; 2) Survey on Social Determinants
of Vaccine Refusal in the Veneto Region. Report available:
http://prevenzione.ulss20.verona.it/indagine_scelta_vaccinale.html
1.) 20112012
Lithuania
Prevalence study
2011
Russian
Federation
Questioning during European Immunization Week
2012
2.) 20092011
Democratic National immunization coverage survey
Republic
of Congo
2012
Eritrea
EPI program review were carried out at national, subnational &district
level &caregivers with technical support from AFRO/IST
2011
Uganda
Social survey on evidence based communication, During SIAs/NIDs:
Independent survey reports, social mobilization survey in 35 districts
2012
Indicator 2:
Countries were asked to provide a measured or estimated percentage of un- and
undervaccinated in whom lack of confidence was a factor which influenced their decision to
get vaccinated. 10% of the countries answering the JRF provided an estimate of un-or
undervaccinated, 90% did not provide any answer to this question. Of the African countries,
45% provided a percentage (Table 3)
Table 3: Number and percentage of countries which provided a measured or estimated
percentage of un- or undervaccinated.
Region
EUR
PAHO
EUR and PAHO
AFR
Numbe
r
Percentage
Number
Percentag
e
Numbe
r
Percentag
e
Numbe
r
Percentag
e
% provided
n= 3
6%
n=5
14%
n=8
10%
n=5
45%
No %
provided
n= 45
94%
n=30
86%
n=75
90%
n=6
55%
Total
n=48
100%
n=35
100%
n=83
100%
n=11
100%
27
Countries from all 3 regions provided percentages, which varied between 0%- 19% of un- or
undervaccinated due to lack of confidence. Czech Republic specified that the percentages
ranged from 9.6-27% according to vaccine. The RD Congo provided a range of percentages,
8% lack of confidence on a national level and percentages ranging from 3.9-15.3% in
different provinces of the country. (Figure 2)
Figure2. Percentage of measured, estimated or unknown (did not specify either from
measured or estimated) of un- and under-vaccinated in whom lack of confidence was a factor
that influenced their decision
Indicator 2- % of un- or undervaccinated due to lack of vaccine confidence
percentage measured
percentage estimated
percentage not indicated
18% (9.6-27%) 19%
4%
0%
0%
0%
1%
4%
10%
8% (3.9-15.3%)
5%
1%
Further the countries were asked to provide comments or specific issues in regard to Indicator
2. (Table 4)
Table 4: Specific comments or issue in regard to indicator 2
Country
Comments or specific issues related to percentage of un- and undervaccinated in whom lack of confidence was a factor that influenced their
decision
Brazil
In the reasons provided, the mothers or caregivers inform that the children
are not vaccinated due to non-acceptance of the vaccine. Others indicate
that reasons for non-vaccination were due to contraindication or adverse
events following immunization.
Cuba
High percentage of acceptance of the population to vaccinate their
children, there is great demand for this service locally (health areas) as
vaccination running in schools and in the adult population.
Germany
Assessment report: http://www.bzga.de/forschung/studien-
28
untersuchungen/studien/?sid=10&sub=64
Grenada
Vaccination confidence is an important factor in understanding reasons
why persons object to vaccination of their children.
Guatemala
Percentage of distrust most common side effects in mothers over 40 years
with no / primary education level.
Iceland
97-99% of parents were positive towards vaccinations.
Saint Lucia
No survey has been conducted to determine lack of confidence in
vaccination of un- and under- vaccinated individuals.
Botswana
EPI manager conducted in 2007 revealed various reasons related to noncompliance to immunization serviced but lack of confidence was not a
factor.
Eritrea
We didn't experience or had a reports from regions that households
lacking confidence influenced decision for un-& undervaccination of their
children.
Guinée
equatorial
Serious issues of hesitancy during the last campagne with parents claiming
vaccine to have caused death of a child. Most parents claim that vaccines
cause illness or death.
Lesotho
Assement of the level of confidence in vaccination has not been done in
the country as a result the country does not have any indication of
confidence levels.
Sao Tomé de
Principe
Lack of confidence is not an issue.
Tanzania
Lost-to-follow up due to nomad population contributes to number of unand undervaccinated.
Democratic
Republic of
Congo
Primarily religious considerations contribute to vaccine hesitancy.
Income status
Of all 94 participating countries, 40% were high income countries, 54% middle income
countries and 6% low income countries. (Table 5)
29
Table 5: Income level of countries by region
Region
EUR
PAHO
AFR
All regions
Numbe
r
Percentag
e
Number
Percentag
e
Numbe
r
Percentag
e
Numbe
r
Percentag
e
High income
n=28
58%
n=7
20%
n=3
27%
n=38
40%
Middle
income
n=18
38%
n=27
77%
n=6
55%
n=51
54%
Low income
n=2
4%
n=1
3%
n=2
18%
n=5
6%
Total
n=48
100%
n=35
100%
n=11
100%
n=94
100%
Indicator 1 and level of income:
One assessment of vaccine confidence had been done in one low income country, 11 in
middle income countries and 6 in high income countries. (Figure 3)
Figure 3: Assessment of vaccine confidence by level of income
6% (n=1)
33% (n=6)
61% (n=11)
High income country
Middle income country
Low income country
Indicator 2 and level of income:
Populations with lack of confidence in vaccinations were reported from all three levels of
income. 13 countries provided a percentage. Of these 3 countries were high income countries,
9 were middle income countries and one country was a low income country.
General comments on the indicators
Two African immunization managers provided specific feedback on the indicators (Table 6);
other used the comment section to further specify their issues in regard to vaccine confidence.
30
Table 6: General comments on the indicators
Might be advisable to conduct a study in each zone
Assessing the level of confidence in vaccine is a good approach in determining the level of
willingness and acceptance of the service and this can be put in place. This will also
contribute in improving immunization services.
Discussion
Overall 94 countries representing all levels of income were included for pilot testing of the
vaccine confidence indicator.
Response differed between the two methods used, with more countries responding an
assessment and a percentage when being asked directly to complete a questionnaire
(immunization managers’ survey in AFR) than when filling in the JRF (PAHO and EUR
region).
In regard to Indicator 1, the assessment of vaccine confidence at a subnational level in the
past, 71% of all countries provided specific feed-back whether this had or had not been done
in their country. 19% of all participating countries had done an assessment of the level of
confidence in their country demonstrating that vaccine confidence was an issue in their
country. 52% had not done an assessment and 29% had not completed the question. For the
29% not providing feedback it was not possible to differentiate whether no assessment had
been done or if the immunization manager filling in the questionnaire/ JRF could not provide
any answer to this question.
In regard to type of assessment countries provided examples from national and subnational
level, hence the question might need to be reworded to have a uniform approach which
captures all types of assessments countries provide feedback on.
Assessments of vaccine confidence had been done in countries of all income levels and not
only in high income countries.
For Indicator 2, only 14% provided a measured or estimated percentage of un- or
undervaccinated in whom lack of confidence was a factor which influenced their decision to
get vaccinated. It needs to be further assessed whether not providing a percentage indicates
that there are no persons with lack of confidence or if it was not feasible for the immunization
manager to provide an estimate. Lack of vaccine confidence ranged from 0% in Cuba,
Dominica, Botswana and Sao Tomé de Prinicpe to 19% in Uganda. These results demonstrate
that the lack of confidence can be significant problem even in countries which would not be
primarily assumed to have issues of vaccine confidence, such as Uganda.
Comments on Indicator 2 represented the large scope of issues around vaccine confidence,
from confidence being an important issue to not being relevant at all. It further unveiled a
31
variety of determinants of vaccine confidence, from religious dimension to safety issues
around the vaccine.
In regard to the format of the JRF, consistency and clarity is needed to receive comparable
results. During this pilot test, there were variations of the form even within one region.
Countries might have been confused using the drop-down selection of YES/NO in regard to
Indicator 2 where in fact they were asked to provide a percentage.
The pilot test demonstrates that vaccine confidence is an issue throughout the three regions
and throughout all levels of income. Issues around vaccine confidence are not restricted to
high income countries in the European or American region, but were also reported from
middle and low income countries and countries in the African region.
The developed indicators need to be further refined by the vaccine hesitancy working group
to provide valid and comparable responses from all countries. Feedback from African
immunization managers was appreciative of the indicators, yet active follow-up with selected
immunization managers from the other regions should be sought to further assess the
feasibility and clarity of the two indicators. ANNEX
32
ANNEX: List of countries by Indicator 1
country
assessment
type
%
measured/
estimated
Antigua and
Barbuda
no
no response
Argentina
no
no response
Bahamas
no
no response
Bolivia
no
no response
Canada
no
no response
Colombia
no
no response
Dominica
no
Ecuador
no
no response
El Salvador
no
no response
Grenada
no
no response
Guyana
no
no response
Haiti
no
no response
Honduras
no
no response
Nicaragua
no
no response
Panama
no
no response
Paraguay
no
no response
Peru
no
no response
Saint Lucia
no
no response
Saint Kitts
and Nevis
no
no response
St Vincent
and the
Grenadines
no
no response
Suriname
no
no response
Trinidad and
Tobago
no
no response
33
0%
estimated
Uruguay
no
no response
Venezuela
no
no response
Belarus
no
no response
Bosnia and
Herzegovina
no
no response
Bulgaria
no
no response
Cyprus
no
no response
Estonia
no
no response
Georgia
no
no response
Hungary
no
no response
Ireland
no
no response
Kyrgyzstan
no
no response
Latvia
no
no response
Norway
no
no response
Republic of
Moldova
no
no response
Romania
no
Slovakia
no
no response
Sweden
no
no response
Tajikistan
no
no response
Ukraine
no
no response
Angola
no
no response
Botswana
no
0%
no response
Burundi
no
5%
estimated
Guinée
equatorial
no
estimated
Lesotho
no
no response
Namibia
no
no response
Sao Tomé
de Principe
no
34
10%
0%
estimated
no response
Tanzania
no
Brazil
yes
Rapid monitoring of vaccination provided
information to explain the reasons for nonvaccination or for abandoning the recommended
vaccination schedule.
Chile
yes
Conducted a small study, requested by the
MINISTRY of Finance in 2012, study focused on
the perception of the National Immunization
Program.
Cuba
yes
Dominican
Republic
yes
Guatemala
yes
Random Survey (1164 mothers / guardians)
house to house. May 2011
4%
measured
Jamaica
yes
Evaluation of the Immunization Program in 2003;
user survey
4%
no response
Mexico
yes
National Survey of Health and Nutrition 2006
Armenia
yes
Belgium
yes
Vaccination coverage study of infants (18-24
months of age) and adolescents in Flanders, 2012.
Czech
Republic
yes
Administrative control
18%
measured
Germany
yes
Representative survey targeting parents of
children aged 0-13 years,
1%
measured
Iceland
yes
Survey among parents
no response
Italy
yes
1.) Survey on communicative and organizational
aspects of vaccination campaign against HPV and
acceptance of the vaccination in the Italian
Regions and proposal for a technical document
for future campaigns (VALORE): REPORT NOT
YET AVAILABLE; 2) Survey on Social
Determinants of Vaccine Refusal in the Veneto
Region: REPORT AVAILABLE:
http://prevenzione.ulss20.verona.it/indagine_scelt
a_vaccinale.html
no response
Lithuania
yes
Prevalence study
measured
35
no response
1%
no response
no response
0%
no response
no response
no response
no response
no response
Russian
Federation
yes
Questioning during European Immunization
Week
no response
Eritrea
yes
In December 2011 EPI program review were
carried out at national , subnational &district
level &caregivers. By the technical support from
AFRO/IST
no response
RD Congo
yes
Enquete national de coverture vaccinale
8%
measured
Uganda
yes
Social survey on evidence based communication.
2012 SIAs/NIDs: Independent survey reports.
2012: SIA: Social mobilization survey to
consultant for 35 districts
19%
measured
36
Appendix 5.2: Pilot Test of Revised 2013 Vaccine Hesitancy Indicators
Pilot Test of revised 2013 Vaccine Hesitancy Indicators
GVAP Strategic Objective 2
Background
Vaccination is considered to be one of public health’s most important achievements.
However, this success has been challenged by anti-vaccine groups and individuals who
question the need, safety and importance of immunizations. Although growing attention on
“vaccine hesitancy” has been emerging at greater rate in recent years, it is not a new
phenomenon. Vaccine hesitancy is an emerging term in the discourse on determinants of
vaccine acceptance where uptake of a vaccine or immunization programme in a community is
lower than would be expected in the context of information given and services available.
Vaccine hesitancy is influenced by a complex network of factors including issues of
complacency, convenience and/or confidence in vaccine(s) or the immunization programme
that may result in refusal, delay or uncertainty towards some or all vaccines. The factors
which influence vaccine acceptance vary by setting and responses need to be locally assessed.
In 2012, the WHO Strategic Advisory Group of Experts on Immunization (SAGE)
established a Working Group to address the issue of vaccine hesitancy which defined vaccine
hesitancy and its scope and identified drivers of vaccine hesitancy. In light of the Decade of
Vaccines Global Vaccine Action Plan, the working group was asked to develop and pilot test
one or several indicator(s) of vaccine confidence that could be used to monitor the issue on a
global and on a national level. As a part of WHO/UNICEF Joint Reporting Form (JRF), a
questionnaire based monitoring tool usually completed by national immunization managers
designed to examine national immunization coverage, reported cases of vaccine-preventable
diseases, immunization schedules and indicators of immunization system performances, the
group had developed and pilot tested a set of two indicators on vaccine confidence. The
indicators consisted of the following questions:
Indicator 1: % of countries that have assessed (or measured) the level of confidence in
vaccination at subnational level.
Question 1:
Has there been some assessment (or measurement) of the level of confidence in vaccination
at subnational level in the past?
Question 2:
If yes, please specify the type and the year the assessment has been done.
Indicator 2: % of un- and under-vaccinated in whom lack of confidence was a fact or
that influenced their decision.
Question 1:
What is the % of un- and under-vaccinated in whom lack of confidence was a factor that
influenced their decision (this applies to all vaccines)?
37
Question 2:
Was this % measured or estimated?
Question 3:
Any comments or specific issue?
The two indicators were pilot tested in the 2012 JRF with the region of the Americas (PAHO)
as well as the European region (EURO). In addition, the two indicators were tested within a
self-administered questionnaires distributed to the IST South & East and Central African
Regional immunization managers’ meetings in 2013 in the African region (AFRO). Pilot
testing within three regions ensured coverage of a broad range of countries representing all
levels of income in order to representatively assess response, comparability and feasibility of
the indicators. Analysis of the collected data revealed a suboptimal response rate indicating
the need for revision of the scope on vaccine confidence as well as the indicators. As a result,
the working group on vaccine hesitancy broadened the scope from vaccine confidence to
vaccine hesitancy and revisited indicator 2 during its December 2013 face-to-face meeting.
Methods
Sampling frame
The WHO EUR region volunteered again to pilot test the revised vaccine hesitancy indicators
in their 2013 UNICEF/WHO JRF. The pilot test was conducted in the WHO EURO region
which supports 53 member states. The JRF for the year of 2013 was sent to the countries in
the region in January 2014, which were asked to return the completed form by 15 April 2014.
Indicators and definition
Given its importance, the working group on vaccine hesitancy decided to keep the previous
indicator 1 only expand to the assessments done on the national level. Indicator 2 was
completely revisited to assess the top 3 reasons for vaccine hesitancy in the country, rather
than providing a measured or estimated percentage of un- and undervaccinated in whom
confidence was an influencing factor in their decision (Indicator 2 in 2012).
Indicator 1: % of countries that have assessed the level of hesitancy in vaccination at a
national or subnational level.
Question 1:
Has there been some assessment of vaccine hesitancy or refusal among the public at national
or sub-national level?
Question 2:
If yes, please provide assessment title(s) and reference(s) to any publication/report.
Indicator 2: Reasons for vaccine hesitancy.
38
Question 1:
What are the top three reasons for not accepting vaccines according to the national schedule?
Question 2:
Is this response based or supported by some type of assessment, or is it an opinion based on
your knowledge and expertise?
The questions were accompanied by a narrative on vaccine hesitancy:
Introduction
Vaccine hesitancy is an emerging term in the discourse on determinants of vaccine
acceptance where uptake of a vaccine or immunization program in a community is lower than
would be expected in the context of information given and services available.
Vaccine hesitancy recognizes that issues of complacency, convenience and/or confidence in
vaccine(s) or immunization programs may all contribute to the delay or refusal of one, some
or almost all vaccines. These factors which influence vaccine acceptance vary by setting and
responses need to be locally assessed.
Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of
vaccine services. Vaccine hesitancy is complex and context specific varying across time,
place, and vaccines. It includes factors such as complacency, convenience, and confidence.
Data collection and analysis
A drop down- list (yes/ no; evidence-based/ opinion) were provided for Indicator 1, Question
1 and Indicator 2, Question 2. For the remaining two questions, free-form text could be
entered. The questions related to the indicators were translated into 2 of the 6 WHO
languages (Russian and English). Completed JRF questionnaires were collected by the
regional office of Europe and later submitted to WHO headquarters in Geneva, Switzerland.
The data collected from the vaccine hesitancy indicators were analysed, summarized using
Microsoft Excel 2010 and compared to the 2012 European JRF data.
Results
Response rate:
The JRF form was sent to all 53 WHO EURO member states. 45/53 countries (85%)
provided a JRF for 2013 by June 26, 2014. Countries which did not provide the JRF were:
Austria, Bosnia and Herzegovina, Bulgaria, Ireland, Italy, Monaco, Poland, and Ukraine. In
2012 ccountries which did not provide a JRF were: Austria, Finland, Monaco, The Former
Yugoslav Republic of Macedonia and Turkey.
Indicator 1:
Indicator 1 assessed whether a measurement of vaccine hesitancy had been done in the
member states at a national or subnational level. The only modification of the indicator to the
previous version included in the 2012 JRF was the expansion of the assessments to the
subnational and the national level.
39
Of those countries which submitted the 2013 JRF, 10/45 (22%) reported an assessment of
vaccine hesitancy and 21/45 (47%) reported not having done an assessment. The questions
were not completed by 14/45 countries (31%). In comparison to the JRF 2012, the response
rate for indicator 1 for the WHO EUR region increased from 52% (25 out of 48) in 2012 to
69% (31 out of 45) in 2013. More countries indicated some form of vaccine hesitancy
assessment in 2013 compared to 2012, 22% (10 out of 45) versus 17% (8 out of 48)
respectively. This decreased non-response by 17 % from 48% within the 2012 EURO JRF to
31% within the 2013 EURO JRF (Table 1).
Table 1. Number of countries reporting an assessment of vaccine hesitancy at a national/ subnational level*.
Region
EUR 2013
Number
EUR 2012
Percentage
Number
Percentage
Assessment
n=10
22%
n= 8
17%
No assessment
n=21
47%
n=17
35%
Question not completed
n=14
31%
n=23
48%
Total
n=45
100%
n=48
100%
*For a complete list of countries and countries by indicator see Annex 1.
Figure 1. Assessment of Vaccine Hesitancy at the National and Sub-national level in 2013
Indicator 1: Assessment of Vaccine-Hesitancy at the National and Sub-national
Level
Assessment
No Assessment
Question not completed
n=14 n=10
31% 22%
n=21
47%
Of the 10 countries which indicated the presence of an assessment, 7 countries provided
assessment title(s) and reference(s) to any publication or report on vaccine hesitancy (Table
2).
40
Table 2. Title(s) and reference(s) to any publication reported on vaccine hesitancy by country
in 2013
Country
Title(s) and reference(s) to publications
Denmark
Wójcik OP, Simonsen J, Mølbak K, Valentiner-Branth P. Validation of the 5-year tetanus,
diphtheria, pertussis and polio booster vaccination in the Danish childhood vaccination database.
Vaccine. 2013 Jan 30; 31(6):955-9. Doi: 10.1016/j.vaccine.2012.11.100. Epub 2012 Dec 13.
Estonia
Estonia participated in VACSATC project
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19181
Germany
1) "representative survey targeting parents of children aged 0-13 years" (German Federal Institute
for Health Education); assessment report: http://www.bzga.de/forschung/studienuntersuchungen/studien/?sid=10&sub=64
2) "KAP study among the general population towards Protection against Infection" (German
Federal Institute for Health Education); assessment report: http://www.bzga.de/forschung/studienuntersuchungen/studien/impfen-und-hygiene/?sub=79
Luxembourg
Krippler S., 2014, « Enquête de couverture vaccinale au Grand Duché de Luxembourg 2012 », Ed.
Ministère de la Santé
Kazakhstan
None indicated on questionnaire
Kyrgyzstan
In 2013 in Kyrgyzstan, with technical support from UNICEF, conducted a study on the quality
perception of the population immunization
Portugal
http://repositorium.sdum.uminho.pt/bitstream/1822/11888/1/Raz%c3%b5es%20de%20Sa%c3%ba
de_Cunha%2cDurand.pdf
Republic of
Moldova
Report of the independent Center for Sociological and Marketing Research CBS-AXA
commissioned by UNICEF and the Ministry of Health of the Republic of Moldova, 2012
Romania
None indicated on questionnaire
Slovakia
None indicated on questionnaire
41
Indicator 2:
Indicator 2 was modified from the previous version included in the 2012 JRF to assess the top
three reasons for not accepting vaccines included in the national schedule. Of the countries
who submitted the 2013 JRF form, 16/45 (36%) provided at least one reason for vaccine
hesitancy while 29/45 (64%) countries did not answer the question (Table 3).
Table 3. Number and percentage of countries which provided a response to top three reasons
for vaccine hesitancy.
Region
EUR
Number
Percentage
Reasons provided
n=16
36%
No reasons provided
n=29
64%
Total
n=45
100%
Countries were further asked whether these reasons were evidence-based or opinion-based
relying on the expertise of the immunization manager. Of the 16 countries that provided
reasons, 7 based their response on evidence and 9 on opinion. The named reasons were
mapped against the matrix of determinants1 developed by the vaccine hesitancy working
group. The list of reasons is indicated by country in Table 4 and summarized within the
matrix of determinants in Figure 2.
1
http://www.who.int/immunization/sage/meetings/2013/april/1_Model_analyze_driversofv
accineConfidence_22_March.pdf?ua=1
42
43
Contextual
Individual/ Social Groups
Vaccine Specific
Reliability and/or Source of Vaccine
Supply
Vaccination Schedule
Role of Healthcare Professionals
Design of Vaccination Program /Mode of
Delivery
Knowledge and Awareness
Health System and Providers-Trust and
Personal Experience
Immunisation as a Social Norm vs. Not
Needed/Harmful
Risk/Benefit (Perceived, Heuristic)
Beliefs, Attitudes and Motivation About
Health and Prevention
Influential Leaders, Gatekeepers and
Anti- or Pro-vaccination Lobbies
Pharmceutical Industry
Religion/Culture/Gender/Socio-economic
Communication and Media Environment
Number of countries naming an
issue related to the determinant
Figure 2. Main themes that were indicated as top three reasons for vaccine hesitancy
Indicator 2: Reasons for Vaccine Hesitancy
9
8
7
6
5
4
3
2
1
0
Table 4. Top three reasons for vaccine hesitancy and basis of response
Country
Top three reasons for vaccine hesitancy
Basis of
response
Belarus
1.
2.
3.
1.
2.
3.
Opinion
Czech
Republic
Denmark
Estonia
Finland
Germany
Iceland
Kazakhstan
Kyrgyzstan
Luxembourg
Malta
Montenegro
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
Republic of
Moldova
1.
2.
3.
Romania
1.
2.
3.
1.
2.
3.
1.
2.
3.
Slovakia
Turkey
44
The large number of negative information on immunization in the media.
Distrust of security used vaccines.
Lack of vaccine-preventable diseases.
The fear of side effects of vaccination.
The lack of knowledge of the course of real diseases.
Perception of pharmaceutical companies like those, whose main interest is
to earn money.
Forgot.
Did not want to be vaccinated.
Other reasons.
Too much different information concerning vaccines and vaccination in
the Internet and media. Whom to trust?
Doubts in vaccine safety.
There are alternative methods of prophylaxis.
Fear of adverse events.
Anthroposophic philosophy.
Religious points of view.
Complacency.
Convenience.
Confidence.
Fear of adverse effects.
Naturalistic views.
Religious.
On personal beliefs (fear of AEFI).
Negative information from the media, internet.
Religious beliefs.
Doubts about the quality and safety of vaccines.
Low public awareness of vaccines.
Fear of adverse effects.
Vaccination not necessary - unserious illness.
Kid was ill the day of the planned immunization.
Fear of adverse reactions.
Anti-vaccine internet sites.
Lack of interest.
Activities of anti-vaccination individuals and groups.
Misinformation through internet.
Sensational approach of media who give a lot of space to everyone who
has something to say against official approach to immunization.
Inadequate communication of medical staff with parents.
Unjustified Medical Contraindications.
Negative publications and TV/radio shows on vaccination and quality of
vaccines.
No presentation on call.
Refusal.
Medical contraindication.
Fear of adverse reactions.
Distrust.
Uselessness.
The side of the vaccines learnt from some websites by the public.
Some religious reasons.
The thought of having so many vaccines (antigens) in the vaccination
schedule and so many administration would be harmful child health.
Opinion
Evidence
Opinion
Opinion
Opinion
Opinion
Evidence
Evidence
Evidence
Opinion
Opinion
Evidence
Evidence
Evidence
Opinion
Conclusion and Discussion
Modifications to the 2013 JRF were threefold: 1) the scope was widened from the more
narrow perspective of vaccine confidence to vaccine hesitancy, which, in addition to vaccine
confidence, includes issues related to convenience and complacency 2) the indicators created
to measure vaccine confidence of JRF 2012 had been refined following poor response rates in
the JRF 2012 questionnaire 3) the narrative included in the JRF was adjusted.
In total more countries reported to have undertaken an assessment or to have not undertaken
an assessment in 2013, which suggests a higher response rate to the similar indicator
implanted in the JRF 2012.
This result may be due to an increased number of assessments amongst the countries in the
EUR region, better understanding of the question convened by the revised narrative or a
result of the inclusion of both national and sub-national assessment in the indicator question
in comparison to only sub-national assessment in 2012. For those countries not responding to
indicator 1, it remains unclear if non-response is a proxy for no assessment or lack of
understanding or willingness to answer the question.
In regard to Indicator 2, 36% (16 out of 45) of the countries responded to the question and
provided reasons for vaccine hesitancy. Response rate to this newly revised indicator was
higher compared to the previous indicator: only 6% (3 out of 48) of the European countries in
2012 had provided a measured or estimated percentage of un- or under-vaccinated in whom a
lack of confidence in vaccination was a factor.
The top three reasons for vaccine hesitancy, categorized by the determinants within the
matrix developed by the vaccine hesitancy working group were 1) Beliefs, attitudes,
motivation about health and prevent, 2) Risk/benefit of vaccines (perceived , heuristic), and
3) Communication and media environment. Major issues were fear of side effects of
vaccination and distrust in the vaccine, lack of perceived risk by vaccine-preventable diseases
and the influence anti-vaccination reports in the media. Interestingly, 3 countries mentioned
unjustified medical contraindications, medical contraindications or the child as being ill the
day of the vaccination as reason for vaccine hesitancy. This was accounted to the
determinant on the role of the health care professional. The issue of false contraindications should be specified within the matrix of determinants.
A plausible reason for the lower response rate on indicator 2 compared to indicator 1 may be
linked to the current structural format of the indicators. Upon analysing the data, it was
found that 67% (14 out of 21) countries who answered “No” to indicator 1 failed to continue
on and answer indicator 2. Meanwhile, only one country of the ten that answered “Yes” to
indicator 1 did not complete indicator 2. This suggests that countries may have believed
that if they answered “No” to indicator 1, they were not required to continue on and
complete the remaining questions of the vaccine hesitancy indicator. The JRF
questionnaire may require some modification to clarify that indicator 1 and 2 are
unrelated and that indicator 2 should be completed regardless of the response in
indicator 1.
45
The overall response rate to both indicators is still suboptimal but not a surprising finding
given that, in general, it takes a time period of approximately 3 years to obtain an adequate
response rate within newly-introduced indicators into the JRF. Nevertheless, compared to the
European JRF in 2012, analysis of the 2013 JRF questionnaire indicates an overall increase in
response to the two indicators.
With further familiarity and adjustment, the vaccine hesitancy indicators of the JRF may
prove to be beneficial in identifying key reasons for vaccine hesitancy and examining
assessment levels at a national and sub-national level. Data on vaccine hesitancy, collected on
an annual basis, will be a potentiating source of information as well as a monitoring tool to
assess potential shifts in the drivers and importance of vaccine hesitancy.
46
ANNEX 1: List of countries by Indicator 1
Member State
Assessment
Andorra
No
Azerbaijan
No
Cyprus
No
Georgia
No
Hungary
No
Latvia
No
Lithuania
No
Norway
No
Spain
No
Sweden
No
Switzerland
No
Tajikistan
No
Uzbekistan
No
Slovenia
No
Montenegro
No
Type
Top 3 Reason
Evidence
1.
2.
3.
Finland
No
Iceland
No
Malta
No
1.
2.
3.
1.
2.
1.
2.
3.
47
Assessment
/Opinion
Based
Activities of antivaccination individuals
and groups
Misinformation through
internet
Sensational approach of
media who give a lot of
space to everyone who
has something to say
against official
approach to
immunization
Fear of adverse events
Anthroposophic
philosophy
Religious points of view
Fear of adverse effects
Naturalistic views
Fear of adverse
reactions
Anti-vaccine internet
sites
Lack of interest
Opinion
Opinion
Opinion
Opinion
Czech Republic
1.
No
2.
3.
Turkey
Belarus
No
But, there are lessons
learnt from the public and
the public health
directorates that day by day
vaccine refusal and groups
against vaccines
1.
2.
3.
1.
No
2.
3.
Opinion
No presention on call
Refusal
Medical
contraindication
Fear of adverse
reactions
Distrust
Uselessness
Evidence
Opinion
Opinion
http://repositorium.sdum.u
minho.pt/bitstream/1822/1
1888/1/Raz%c3%b5es%20d
e%20Sa%c3%bade_Cunha%
2cDurand.pdf
Portugal
Yes
Romania
Yes
1.
2.
3.
Slovakia
Yes
1.
2.
3.
48
The fear of side effects
of vaccination
The lack of knowledge
of the course of real
diseases.
Perception of
pharmaceutical
companies like those,
whose main interest is
to earn money.
The side of the vaccines
learnt from some
websites by the public.
Some religious reasons
The thought of having
so many vaccines
(antigens) in the
vaccination schedule, so
much administrations
would be harmful child
health
наличие большого
количества негативной
информации по
иммунизации в СМИ
[the large number of
negative information on
immunization in the
media]
недоверие к
безопасности
применяемых вакцин
[distrust of security
used vaccines]
отсутствие
вакциноуправляемых
инфекций [lack of
vaccine-preventable
diseases]
Evidence
Germany
Yes
1) "representative survey
targeting parents of children
aged 0-13 years" (German
Federal Institute for Health
Education); assessment
report:
http://www.bzga.de/forsch
ung/studienuntersuchungen/studien/?si
d=10&sub=64
2) "KAP study among the
general population towards
Protection against Infection"
(German Federal Institute
for Health Education);
assessment report:
http://www.bzga.de/forsch
ung/studienuntersuchungen/studien/im
pfen-und-hygiene/?sub=79
1.
2.
3.
Complacency
Convenience
Confidence
Opinion
Estonia
Yes
Estonia participated in
VACSATC project
http://www.eurosurveillanc
e.org/ViewArticle.aspx?Artic
leId=19181
1.
Too much different
information concerning
vaccines and
vaccination in the
Internet and media.
Whom to trust?
Doubts in vaccine safety
There are an alternative
methods of prophylaxis
Forgot
Did not want to be
vaccinated
Other reasons
Opinion
2.
3.
Denmark
49
Yes
Wójcik OP, Simonsen J,
Mølbak K, Valentiner-Branth
P. Validation of the 5-year
tetanus, diphtheria,
pertussis and polio booster
vaccination in the Danish
childhood vaccination
database. Vaccine. 2013 Jan
30; 31(6):955-9. Doi:
10.1016/j.vaccine.2012.11.1
00. Epub 2012 Dec 13.
1.
2.
3.
Evidence
Kyrgyzstan
Kazakhstan
Yes
Yes
В 2013 году в Кыргызстане,
при технической
поддержке ЮНИСЕФ
проведено исследование
по качественному
восприятию населения
иммунизации [In 2013 in
Kyrgyzstan, with technical
support from UNICEF,
conducted a study on the
quality perception of the
population immunization]
1.
в работе
1.
2.
3.
2.
3.
Luxembourg
Republic of
Moldova
Yes
Yes
Krippler S., 2014, « Enquête
de couverture vaccinale au
Grand Duché de
Luxembourg 2012 », Ed.
Ministère de la Santé
1.
2.
Отчет независемого
Центра Социологических и
Маркетенговых
исследований CBS-AXA по
заказу ЮНИСЕФ и МЗ РМ,
2012 год
1.
3.
2.
3.
50
По религиозным
убеждениям [religious
beliefs]
Сомнения в качестве и
безопасности вакцин
[Doubts about the
quality and safety of
vaccines]
Низкая
информированность
населения в вопросах
вакцинопрофилактики
[Low public awareness
of vaccines]
П
одкреплен
о фактами
[supported
by facts]
религиозные
[religious]
по личным
убеждениям (боязнь
НППИ) [on personal
beliefs (fear of AEFI)]
негативная
инфорамция со
стороны СМИ,
интернет [negative
information from the
media, internet]
Fear of adverse effects.
Vaccination not
necessary - unserious
illness.
Kid was ill the day of
the planned
immunization.
Недостаточная
коммуникация
медперсонала с
родителями
[Inadequate
communication of
medical staff with
parents]
Необоснованные
медотводы [Unjustified
medical
contraindications]
Отрицательные
публикации и
передачи о
вакцинации и качестве
вакцин [Negative
publications and
TV/radio shows on
vaccination and quality
of vaccines.]
Подкрепле
но фактами
[supported
by facts]
Evidence
Подкрепле
но фактами
[supported
by facts]
Appendix A5.3 Vaccine Hesitancy Survey Questions Related to SAGE
Vaccine Hesitancy Matrix
Examples of survey questions designed to assess determinants of vaccine
hesitancy
Vaccine hesitancy is an emerging term in the literature and discourse on vaccine decision-making
and determinants of vaccine acceptance.i To date various surveys have been developed to assess
individual attitudes as well as concerns around the risks and benefits immunizationii,iii,iv,v,vi,vii yet few
surveys are available to specifically assess or measure the prevalence or degree of vaccine hesitancy
in a populationviii,ix. Even less surveys have been validatedx,xi. In addition the majority of available
surveys has been conducted in high income countries and predominately focuses on identifying
vaccine hesitancy at the individual level only and not its underlying determinants.
A universally validated compendium of survey questions is needed to identify vaccine hesitant
populations and the drivers of their reluctance at the global, national or subnational level, in order
to tailor targeted interventions aiming at increasing vaccine acceptance and ultimately immunization
rates. A standardized compendium of survey questions would further ensure intra- and intercountry
comparison of the determinants leading to vaccine hesitancy.
The SAGE Working Group on Vaccine Hesitancyxii defined the term Vaccine Hesitancy:
“Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccine
service. Vaccine hesitancy is complex and context specific varying across time, place and vaccines. It
is influenced by factors such as complacency, convenience and confidence.”
In addition the Working Group developed a model of determinants of vaccine hesitancy, based on a
systematic review of literature i and interviews with immunization managers, which categorized
drivers into contextual influences, individual and group influences and vaccine or vaccination specific
issuesxiii. The model of determinants was seen as a useful tool to guide the selection of survey
questions sensitive and specific to vaccine hesitancy in order to provide information not only on the
overall prevalence of vaccine hesitancy but also its underlying determinants.
The Working Group developed de-novo survey questions tailored to the specific determinant. In
addition, survey questions x from a validated parental assessment instrument of vaccine hesitancy
were categorized to fit the specific determinants.
The working group notes that these example survey questions represent a range of questions to
draw from which could be considered based on the circumstances and context. The list of example
survey questions can be found in the Table A5.3 .1, Table A5.3.1 and Table A5.3.2 below. Questions
highlighted in italics bold, are question within the 18 item-containing validated Parent Attitudes
about Childhood Vaccines (PACV) survey to assess vaccine hesitant parents in the US x. Factor
analysis was used to confirm survey sub-domains and Cronbach's α to determine the internal
consistency reliability of sub-domain scales. Construct validity was assessed by linking parental
responses to their child's immunization record xi.
The listed example questions are not intended to all be used within one questionnaire but rather
present a set of questions to be considered and chosen from based on the individual needs. The
Working Group acknowledges that the survey question selection needs to fit the context they are
used in. Construct and content validity to assess the individual determinant of vaccine hesitancy of
this survey question compendium needs to be assessed. To further ensure that the objective of the
compendium is met, the assessment of vaccine hesitancy and its determinants within various
settings covering all levels income, pilot-testing of these survey questions needs to be ensured in
low-, middle and high-income countriesxiv within all 6 WHO regionsxv. Particular attention needs to
be given to ensuring validity when translating the compendium to languages other than English.
Based on the results of this pilot-testing, questions may need to be added or altered.
51
Table A5.3 .1: Survey questions to assess contextual influences of vaccine hesitancy
CONTEXTUAL INFLUENCES
Influences arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors
a.
Communication and
media environment
Media and social
media can create a
negative or positive
vaccine sentiment and can
provide a platform for
lobbies and key opinion
leaders to influence others;
social media allows users
to freely voice opinions
and experiences and it can
facilitate the organization
of social networks for or
against vaccines.
b. Influential leaders,
gatekeepers and
anti- or pro-vaccination
lobbies
Community leaders and
influencers, including
religious leaders in some
settings, celebrities in
others, can all have a
significant influence on
vaccine acceptance or
hesitancy.
Who do you trust the most
for information?
Who do you trust the
least?
Some groups or leaders do
not agree to vaccination
for different reasons. In
general, do you agree or
disagree with these
groups?
Have reports you
heard/read in the media/
on social media made you
re-consider the choice to
have your child
vaccinated?
Do leaders (religious,
political, teachers, health
care workers) in your
community support
vaccines for infants and
children?
52
c. Historical influences
Negative historic
influences such as the
Trovan trial/ Wakefield
MMR-autism scare can
undermine public trust
and influence vaccine
acceptance, especially
when combined with
pressures of influential
leader/media. Community
experience isn’t
necessarily limited to
vaccination but may affect
it.
Do you remember any
events in the past that
would discourage you
from getting a vaccine(s)
for yourself or your
children?
Can you name an event in
the past that diminished
your trust in vaccination?
d. Religion/culture/gender/
socio-economic
A few examples of the
interplay of religious/cultural
influences include:
Some religious leaders prohibit
vaccines
e. Politics/policies
(Mandates)
f. Geographic barriers
g. Pharmaceutical
industry
Vaccine mandates can
provoke vaccine hesitancy
not necessarily because of
safety or other concerns,
but due to resistance to
the notion of forced
vaccination
A population can have
general confidence in a
vaccine and health service,
and be motivated to
receive a vaccine but
hesitate as the health
center is too far away or
access is difficult.
Industry may be distrusted
and influence vaccine
hesitancy when perceived
as driven only by financial
motives and not in public
health interest; This can
extend to distrust in
government when
perceived that they are
also being pushed by
industry and not
transparent.
Do you trust (or distrust)
that your government is
making decisions in your
best interest with respect
to what vaccines are
provided?
Has distance, timing of
clinic, time needed to get
to clinic or wait at clinic
and/or costs in getting to
clinic prevented you from
getting your child
immunized?
Do you believe the vaccine
producers are interested
in your health?
Did you ever disagree
with the choice of vaccine
or vaccination
recommendation
provided by your
government?
The time/cost/effort of
traveling to the
doctor/health post/ clinic
with young children is not
worth for receiving
vaccination only?
Do you think governments
are “pushed” by lobbyists
or industry to recommend
certain vaccines?
Some cultures do not want
men vaccinating children
Some cultures value boys over
girls and fathers don’t allow
children to be vaccinated).
Do you know anyone who
does not take a vaccine
because of religious or
cultural reasons? Do you
agree or disagree with these
persons? Do you think they
are risking their health or the
health of their child if they do
not take a vaccine?
Does your religion/
philosophy/ culture
recommend against (a certain)
vaccination? If so, which/all
vaccines? What is the reason?
Do you share information
related to vaccination
within your social media
network? What type of
information?
Would it trigger doubts to
have your child
vaccinated, if a celebrity
advocates against (a
certain) vaccine?
Has your community ever
felt the need to urgently
introduce a new vaccine?
What do you consider more
important- vaccination of
boys or vaccination of girls?
Why?
I’m convinced that my
government purchases
the highest quality
vaccines available.
What is the maximum
amount of time you would
be able or willing to spend
to get a vaccine for
yourself or your children?
Do you recall a vaccine
that was positively
debated in the media? If
so, which one and would
you still want this vaccine
for yourself/ your child?
Do you believe in reports
in the media by parents
claiming to have lost a
child to a vaccine
preventable disease? Does
this affect your decision to
vaccinate your child?
Has your imam/priest/
rabbi ever advocated
against vaccination? Did
you follow this advice?
Has your community in
the past refused to accept
certain vaccines? Which
vaccine(s) and why?
Have you ever refused a
vaccine as you considered it
to include porcine or other
animal derived ingredients
(non-halal, non-kosher)?
Did you ever have the
impression your
government/health care
provider did not provide
you with the best vaccine
on the market?
The only reason I have
my child get shots is so
they can enter daycare or
school.
If you have to spend more
than one hour getting a
vaccine, is it important
enough to travel for it?
Would you refuse a vaccine
for you/your child if the
vaccinator was male/female
or from a different ethnic
background/religion than
yourself?
Does your child’s
daycare/ school require/
advice to have your
children vaccinated? Do
you agree?
53
Has your life-style
(nomadic/ located in
different places throughout
the course of the year)
ever prevented you to
receive a vaccine for
yourself/your child?
Do you trust
pharmaceutical companies
to provide safe and
effective vaccines?
Table A5.3.1: Survey questions to assess individual and group influences of vaccine hesitancy
INDIVIDUAL and GROUP INFLUENCES
Influences arising from personal perception of the vaccine or influences of the social/peer environment
a. Experience with past
vaccination
b.Beliefs, attitudes about
health and prevention
c.Knowledge/awareness
d. Health system and providerstrust and personal experience.
e. Risk/benefit (perceived,
heuristic)
f. Immunisation as a social
norm vs. not needed/harmful
Past negative or positive
experience with a particular
vaccination can influence
hesitancy or willingness to
vaccinate.
Knowledge of someone who
suffered from a VPD due to nonvaccination may enhance
vaccine acceptance. Personal
experience or knowledge of
someone who experienced an
AEFI (adverse event following
immunization) can also
influence hesitancy.
Vaccine hesitancy can result
from 1) beliefs that vaccine
preventable diseases (VPD) are
needed to build immunity (and
that vaccines destroy important
natural immunity) or 2) beliefs
that other behaviors
(breastfeeding,
traditional/alternative medicine
or naturopathy) are as or more
important than vaccination to
maintain health and prevent
VPDs.
Decisions to vaccinate or not are
influenced by a number of the
factors addressed here,
including level of knowledge and
awareness. Vaccine acceptance
or hesitancy can be affected by
whether an individual or group
has accurate knowledge, a lack
of awareness due to no
information, or misperceptions
due to misinformation.
Accurate knowledge alone is not
enough to ensure vaccine
acceptance, and misperceptions
may cause hesitancy, but still
result in vaccine acceptance.
Trust or distrust in government
or authorities in general, can
affect trust in vaccines and
vaccination programmes
delivered or mandated by the
government. Past experiences
that influence hesitancy can
includes system procedures that
were too long or complex, or
personal interactions were
difficult.
Perceptions of risk as well as
perceptions of lack of risk can
affect vaccine acceptance.
Complacency sets in when the
perception of disease risk is low
and little felt need for
vaccination. E.g. Patient’s or
caregiver’s perceptions of their
own or their children’s risk of
the natural disease or
caregivers’ perceptions of how
serious or life threatening the
VPD is.
Vaccine acceptance or hesitancy
is influenced by peer group and
social norms
Have you ever not accepted a
vaccination for your child?
What was the reason?
Can you tell me what a vaccine
is? What does it do to the body?
Do you feel that you know
which vaccines you should get
for yourself? Your children?
How concerned are you that
any one of the childhood shots
might not be safe?
Most children tolerate
vaccination very well.
It is my role as a parent to
question shots.
I agree that it is important for
everyone to get the
recommended vaccines for
themselves and their children.
Do you think that most parents
like you have their children
vaccinated with all the
recommended vaccines?
Have you or someone you know
ever had a bad reaction to a
vaccine which made you
reconsider getting vaccines?
Do you think it is possible to
have received too many
vaccines at one time?
Do the vaccinators in door-todoor or mass immunization
campaigns provide you with
sufficient information to
address your concerns around
vaccination?
Did you ever inform yourself on
a certain vaccine and then
decide against it/delay receiving
it? If so, why, which vaccine and
what resources did you use?
Information on side-effects
following immunization is
discussed openly by the
authorities.
Have you ever felt healthcare
professional, government, local
authorities are pushing you into
a vaccination decision you did
not fully support? Why?
Does having the same provider
give all the infant vaccines make
you more likely to accept
vaccines than having a different
provider each time vaccines are
due?
I believe that many of the
illnesses shots prevent are
severe.
54
Do you think vaccines are still
needed even when the disease
is no longer prevalent?
Do you think it’s important to
get a vaccine to protect those
that cannot get vaccinated?
Do you know of a child with a
serious disease/ disability
because they were not
vaccinated?
Do you think vaccines overload
the immune system?
Do you feel you get enough
information about vaccines and
their safety?
I am able to openly discuss my
concerns about shots with my
child’s doctor.
How concerned are you that
your child might have a serious
side effect from a shot? x
Do you know of anyone who
has had a bad reaction to a
shot?
It is better for my child to
develop immunity by getting
sick than to get a shot.
I trust the information I receive
about shots.
How concerned are you that a
shot might not prevent the
disease?
Have you heard of anyone who
was disabled after receiving a
vaccine? Did this make you
reconsider your choice to get
yourself/ your child vaccinated?
Do experiences with pain with
past immunization prevent you
or your child form being
immunized?
Do you believe that there are
other (better) ways to prevent
diseases which can be
prevented by a vaccine?
Would you prefer to receive
more information on
vaccination at your health
center? Do you think this would
change your choice in favor of a
vaccine?
My health professional/HCW’s
provides me with all the
information I need to my
questions on immunization.
Do you feel that your health
care provider cares about what
is best for your child?
Measles/polio/diphtheria is not
common where I live. That’s
why I decided against the
vaccine.
55
Do you believe that it is better
for the child to start to receive
them only when over one year
of age?
Do you believe that shots are
given to babies when they too
young?
Do you consider that some
vaccines are more important
than other? Which vaccine(s)
and why?
Do you believe that vaccines are
still needed when diseasesare
rare?
Do the mothers/fathers in your
community/ circle of friends
have their child vaccinated? Do
you have your child vaccinated?
Why?
Do you believe that if you
vaccinate your child, others are
protected as well?
Are you worried that some
mothers in your community are
delaying or refusing vaccines,
putting your infant at risk for
these diseases e.g. pertussis ?
Table A5.3.2: Survey questions to assess vaccine/vaccination specific issues of vaccine hesitancy
VACCINE/ VACCINATION -specific issues
Directly related to vaccine or vaccination
a. Risk/ Benefit
(scientific evidence)
b. Introduction of a
new vaccine or new
formulation
c. Mode of
administration
Scientific evidence of
risk/benefit and history
of safety issues can
prompt individuals to
hesitate, even when
safety issues have been
clarified and/or
addressed
e.g. suspension of
rotavirus vaccine due
to intussusception;
Guillain-Barre
syndrome following
swine flu vaccine
(1976) or narcolepsy
(2011) following
(A)H1N1 vaccination;
milder, local adverse
events can also
provoke hesitancy.
Individuals may hesitate
to accept a new vaccine
when they feel it has
not been used/tested
for long enough or feel
that the new vaccine is
not needed, or do not
see the direct impact of
the vaccine (e.g. HPV
vaccine preventing
cervical cancer).
Individuals may be more
willing (i.e. not
complacent) to accept a
new vaccine if
perception of the VPD
risk is high.
Mode of administration
can influence vaccine
hesitancy for different
reasons. E.g. oral or
nasal administrations
are more convenient
and may be accepted
by those who find
injections fearful or
they do not have
confidence in the
health workers skills or
devices used.
Do you believe
vaccines are safe for
yourself? Your
child/children? For
those in your
community?
What is the first thing
you want to know when
a new vaccine is
introduced or
announced? Would you
rather wait
and see what other
Is there any mode of
vaccination you would
not want?
56
d. Design of
vaccination
program/Mode of
delivery
Delivery mode can
affect vaccine
hesitancy in multiple
ways. Some parents
may not have
confidence in a
vaccinator coming
house-to-house; or a
campaign approach
driven by the
government.
Alternatively if a health
center is too far or the
hours are inconvenient
Is the vaccination
process welcoming?
Are there any things
that could be done to
make it easier for you
to get vaccines (on
time) for yourself or
e. Reliability and/or
source of vaccine
supply
f. Vaccination schedule
g. Costs
h. Role of healthcare
professionals
Individuals may
hesitate if they do not
have confidence in the
system’s ability to
provide vaccine(s) or
might not have
confidence in the
source of the supply
(e.g. if produced in a
country/culture the
individual is suspicious
of); HCWs may also be
hesitant to administer
a vaccine (especially a
new one) if they do not
have confidence that
the supply will continue
as it affects their clients
trust in them.
Caregivers may not
have confidence that a
needed vaccine and/or
health staff will be at
the health facility if
they go there.
Do you feel confident
that the health center
or doctor’s office will
have the vaccine you
need, when you need
them?
Although there may be
an appreciation for the
importance of
preventing individual
vaccine preventable
diseases, there may be
reluctance to comply
with the recommended
schedule (e.g. multiple
vaccines or age of
vaccination).
An individual may have
confidence in a
vaccine’s safety and
the system that delivers
it, be motivated to
vaccinate, but not be
able to afford the
vaccine or the costs
associated with getting
themselves and their
child(ren) to the
immunization point.
Alternatively, the value
of the vaccine might be
diminished if provided
for free.
Health care
professionals are
important role models
for their patients; if
they hesitate for any
reason (e.g. due to lack
of confidence in a
vaccine’s safety or
need) it can influence
their clients’ willingness
to vaccinate
Would the cost of a
vaccine prevent you
from getting it, even if
you felt you or your
child needed it?
Did healthcare
professionals ever treat
you without respect
(e.g. in regard to your
appearance, education
or cultural background) so
that you will hesitate to
Vaccination schedules
have some flexibility
that may allow for
slight adjustment to
meet individual needs
and preferences. While
this may alleviate
hesitancy issues,
accommodating
individual demands are
not feasible at a
population level.
Are there any vaccines
that are difficult for you
to get because of the
schedule?
people do?
your children?
Me or my child never
experienced severe
adverse reactions
following
immunization.
experience an AEFI and
I consider rotavirus
vaccine/ HPV vaccine/
meningococcal vaccine/
pentavalent vaccine to
be safe.
Do you fear the pain/
to you/your child or
fear the needles when
receiving a vaccine
make you hesitate be
to immunized?
Would you rather
receive a vaccine as
conveniently as
possible or with as
much medical
consultation as
possible? Why?
Do you consider some
vaccine products
preventing a disease
(influenza-LAIV or
standard/ measles (M
only or MMR) safer
than others?
Do you feel your child
to be at risk of diarrhea/
cervical cancer? Do you
think a vaccine is
needed to prevent
these diseases?
Has pain following
immunization ever
made you reconsider
to have yourself/ your
child vaccinated?
Before administering
the vaccine, my health
care worker (HCW)
always provided me
with enough
information on the
side-effects that might
follow.
New vaccines are not
trialed to the same
rigorous standard as
any normally prescribed
drug?
Would you be willing to
accept more vaccines
for yourself/ your child
if there was no pain
involved?
What would you prefer
for yourself/your child:
Receive a vaccine at
your health center/
from your doctor or
from door-to-door
vaccinators/ during
mass vaccination
campaigns/ schoolbased programs? Why?
Would you let your
child get vaccinated
within a school-based
immunization
program? If yes, what
are the advantages?
Have you ever delayed
vaccinating your child
with a newly
introduced/
recommended vaccine?
Why?
Do you trust your HCW
to safely administer the
vaccine to you/ your
child?
References: Please see p. 105
57
Did you ever refrain
from having yourself/
your child vaccinated
during a mass
immunization
campaign? Why?
return to the healthcare
facility?
Did you ever not
return to a health
center/ your doctor
after not receiving the
vaccine during an
initial visit? What were
the reasons why you
did not receive the
vaccine initially?
Have you ever been
sent home from the
health center/ doctor’s
office due to lack of
vaccine? If so, did you
go again to try and
receive it?
How sure are you that
following the
recommended shot
schedule is a good idea
for your child?
If you had another
infant today, would
you want him/her to
get all the
recommended shots?
Which medication do
you consider more
effective- the free-ofcharge drugs provided
at your health care
center/doctor/ by your
government or the
ones you need to pay
for yourself? Why?
Do you consider all
important vaccines
provided/ covered by
your health insurance/
health care plan/
health care provider?
Would you pay for
additional vaccines
yourself?
Did you choose your
doctors based on their
willingness to alter or
delay the vaccination
schedule according to
your requests?
Has your healthcare
provider ever advised
you that a certain
vaccine was not
necessary or had too
many side effects?
Which one?
At your health center,
did you ever not
receive a vaccine as
the HCW indicated
there were too few
people to start
vaccinating?
Children get more
shots than are good
for them.
I wouldn’t mind taking
time off from work to
make sure my child
gets vaccinated?
Was your doctor ever
reluctant to administer
a vaccine you wanted
for yourself/ your
child? Which vaccine
and why?
Did you ever decide
against a vaccine as it
was produced by a
manufacturer you did
not trust? Do you
believe vaccines made
in Europe or America
are safer than those
made in middle
income countries?
It is better for children
to get fewer vaccines
at the same time.
Would you be willing to
pay for a vaccine
privately? If so, for
which ones?
Do you trust the doorto-door vaccinators?
Appendix A5.4 WHO EUR Tailoring Immunization Program (TIP)
The TIP framework can be accessed:
http://www.euro.who.int/The-Guide-to-Tailoring-Immunization-Programmes-TIP.pdf
Appendix A5.4.1:Principles for TIP
PSI Delta Marketing Planning Process 7 Steps ; Principles of TIP
1.
The Situation Analysis analyzes the context in which the intervention operates in order to
ensure selection of the most appropriate target group and behavior, and identify strategic
priorities for the marketing plan.
2. Audience Insight means getting to know the target group as a real person – one with a face
and a name – and one with aspirations and desires, not just as a bunch of demographics.
Creating such profiles is a technique that has been used successfully by commercial sector
giants such as Proctor and Gamble.
3. Brand Positioning is the identification and promotion of the most important and unique
benefit that the product/ service/ behavior stands for in the mind of the target group. This is
the emotional “hook” upon which one can hang the marketing strategy.
4. Marketing Objectives specify what you want to achieve during the marketing plan, ensuring
it stays focused and true to the evidence. This also facilitates easier monitoring of
intervention progress.
5. The Four Marketing “P’s” – Product, Price, Place and Promotion -- specify what strategies
one will use to achieve the marketing objectives.
6. The Research Plan details how the intervention will monitor and evaluate implementation of
the plan, as well as identifying and prioritizing any information gaps about the target group
and how they will be explored.
7. An integrated Budget and Work Plan specify how financial resources will be allocated among
the 4Ps and help managers allocate human and other resources as well as monitor
implementation.
58
Appendix for Section 6.
Appendix A6A.1 Executive Summary of the Systematic Review on Strategies
to address vaccine hesitancy
The full systematic review document is published on the SAGE share point. After the SAGE October
2014 meeting, the systematic review will be published on the WHO SAGE website.
EXECUTIVE SUMMARY
EXECUTIVE SUMMARY
SAGE working group dealing with vaccine hesitancy – Systematic Review of Strategies
Introduction
The purpose of the systematic review of strategies for addressing vaccine hesitancy is to identify
strategies that have been implemented and evaluated across diverse global contexts in an effort to
respond to, and manage, issues of vaccine hesitancy. This is to fulfil the requirements of the SAGE
working group (WG) dealing with vaccine hesitancy in respect to:
a) identifying existing and new activities and strategies relating to vaccines or from other areas that
could successfully address vaccine hesitancy;
b) identifying strategies that do not work well, and;
c) prioritising activities and strategies based on an assessment of their potential impact.
These requirements were translated into the following specific objectives:
1. Identify published strategies related to vaccine hesitancy and hesitancy of other health
technologies (reproductive health technologies (RHT) were chosen as the additional focus)
and provide a descriptive analysis of the findings;
2. Map all evaluated strategies to the SAGE WG “Model of determinants of Vaccine Hesitancy”
(Appendix 1) and identify key characteristics;
3. Evaluate relevant evaluated strategies relating to vaccine hesitancy using GRADE (Grades of
Recommendation, Assessment, Development and Evaluation); relevance was informed by
the PICO questions defined a priori by the WG, and;
4. Synthesise findings in a manner which aids the design of future interventions and further
research.
Methods
Objective 1 - A systematic literature review methodology was applied to access and assess both peerreviewed and grey literature. Interventions relating to hesitancy towards RHT were analysed to
obtain greater insights surrounding lack of uptake of available health technologies and to ascertain
whether strategies aimed at addressing hesitancy towards RHTs could be adopted to address vaccine
hesitancy.
59
Objective 2 – Characteristics of evaluated interventions were mapped against the SAGE WG Model of
determinants of vaccine hesitancy and also grouped according to one of four identified themes which
characterise the type of intervention:
i)
ii)
iii)
iv)
Multi-component
Dialogue-based
Incentive-based
Reminder/recall-based
Objective 3 - The GRADE approach was applied for grading the quality of evidence of a selection of
peer-reviewed primary studies that evaluated interventions; selection was based on the relevance of
studies to the fifteen PICO questions set out a priori by the SAGE WG (Table 2). These questions
were developed under one of three intervention themes (further defined below): 1) Dialogue-based,
2) Incentive-based (non-financial), and 3) Reminder-recall. The multi-component theme was
excluded in this section because of a preference expressed by the WG to focus on identifying and
assessing the impact of single component approaches. However, data were included where a multicomponent intervention provided suitable data to assess the effect of its individual component parts.
Risk of bias was assessed for each study and the evidence was set out against each individual PICO
question.
Theme categories for PICO questions:
i)
Dialogue-based, which included the involvement of religious or traditional leaders,
social mobilisation, social media, mass media, and communication or information-based
tools for health care workers;
ii)
Incentive-based (non-financial), which included the provision of food or other goods to
encourage vaccination, and;
iii)
Reminder/recall-based, including telephone call/letter to remind the target population
about vaccination.
There were two outcomes of interest:
1. Outcome 1: Impact on vaccination uptake (behavioural shift);
2. Outcome 2: Impact on vaccine/vaccination knowledge/awareness and/or attitude
(psychological shift).
Results
Objective 1. Identification of published interventions and descriptive analysis of the findings
Table 1 sets out the number of studies identified across the literature that acknowledged
interventions relating to hesitancy (vaccines and RHTs), and whether these were evaluated or not. All
evaluated interventions were coded by country, WHO region†, target vaccine, target population and
publication year.
†
The World Health Organization (WHO) divides the world into six WHO regions, for the
purposes of reporting, analysis and administration: WHO African (AFR), WHO region of the
60
Table 1. Number of studies identified across peer-reviewed and grey literature by hesitancy
(vaccine/reproductive health technologies) and intervention type (evaluated/suggested)
Peerreviewed
literature
Vaccine
Hesitancy
Grey
literature
Hesitancy
around
Grey
Reproductive
literature
Health
Technologies
Primary studies
identified
Evaluated
intervention
Suggested
intervention
Studies/articles
identified
Evaluated
intervention
Suggested
intervention
Studies/articles
identified
Evaluated
intervention
Suggested
intervention
Total
count
Outcome 1
Outcome 2
Outcomes 1
&2
1149
-
-
-
166
(14%)
115 (69%)
37 (22%)
14 (9%)
983 (86%)
-
-
-
59
-
-
-
15 (25%)
9 (60%)
3 (20%)
3 (20%)
44 (75%)
-
-
-
51
-
-
-
13 (25%)
4 (31%)
2 (15%)
7 (54%)
38 (75%)
-
-
-
Overall, for the period January 2007-October 2013, the number of peer-reviewed studies evaluating
interventions peaked in 2011 and has remained relatively stable since. However, only five studies
actually used the terms ‘vaccine hesitant/hesitancy’, which indicates the relative newness of the
concept and use in research vernacular. Studies that did not explicitly mention vaccine hesitancy
were however retained because they indicated research on conceptually similar issues that matched
one or more of the determinants of vaccine hesitancy as set out in the SAGE WG model of
determinants of vaccine hesitancy. Very few evaluated interventions were identified in the grey
literature with one or two articles annually at most from 1996-2012. However, in 2013, eight
relevant articles were found.
Objective 2. Mapping of evaluated strategies and identification of key characteristics.
Vaccine hesitancy
The majority of evaluated studies were based in the AMR region and primarily focused on influenza,
HPV and childhood vaccines. In low- and middle-income regions, particularly SEAR and AFR, the
focus was on DTP and polio. All regions had studies anticipating or researching acceptance of the
newly introduced HPV vaccine.
Americas (AMR), WHO South East Asia (SEAR) WHO European (EUR), WHO Eastern
Mediterranean (EMR) and WHO West Pacific (WPR).
61
Most interventions targeted parents, healthcare workers and the local community/parents (found
mostly in the AMR and EUR regions). Interventions from the AFR region dominated the grey
literature and tended to focus on the local community and religious leaders.
When the interventions were assessed against the SAGE WG model of determinants of vaccine
hesitancy, the most common type of intervention sought to address individual and social group
influences such as using knowledge and awareness raising strategies. For vaccine and vaccinationspecific interventions, approaches focused mainly on mode of delivery and the role of healthcare
professionals. The engagement of religious and other community leaders was most commonly
applied to address contextual influences of vaccine hesitancy such as religious, cultural and gender
issues.
Across all the literature and WHO regions, most of the interventions were multi-component.
Dialogue-based interventions were common in all regions except EMR; reminder –recall approaches
featured predominantly in higher-income regions; and, incentive-based interventions were only
found in AMR and AFR (single-component), and SEAR (part of a multi-component approach).
Which interventions have been most successful?
Overall for Outcome 1 (vaccination uptake) , the interventions with the largest positive effect
estimates are those that (not in order of importance): 1) directly target unvaccinated or undervaccinated populations; 2) aim to increase knowledge and awareness surrounding vaccination; 3)
improve convenience and access to vaccination; 4) target specific populations such as the local
community and HCW; 5) mandate vaccinations or impose some type of sanction for non-vaccination;
5) employ reminder and follow-up; and 6) engage religious or other influential leaders to promote
vaccination in the community. For Outcome 2 (psychological shift), the introduction of education
initiatives, particularly those that embed new knowledge into a more tangible process (e.g., hospital
procedures, individual action plans), were most successful at increasing knowledge and awareness
and changing attitudes. For both outcomes, some education/awareness strategies are, of course,
better than others. In particular, those that tailor the intervention to the relevant populations and
their specific concerns or information gaps are most effective. Altogether, the most effective
interventions employed a number of these strategies (multi-component interventions) to increase
vaccine uptake, knowledge and awareness and shift attitudes towards pro-vaccination.
Which interventions have been least successful?
In general, interventions that focused on quality improvement strategies (e.g., standing orders,
improved data collection and monitoring, extended clinic hours) at clinics did not reap great changes
in vaccine uptake. Similarly, interventions that adopted interventions that were only applicable to
the individual from a distance (e.g., posters, websites, media releases, radio announcements)
brought little benefit. Incentive-based interventions using either conditional or non-conditional cash
transfers were not successful, although these interventions were usually targeting general preventive
health engagement and not just vaccination. Lastly, while reminder-recall interventions have been
shown to be effective, they can also be ineffective. These findings highlight the importance of not
generalising interventions before understanding the different target audiences, vaccine of interest
and setting.
RHTs
Interventions relating to hesitancy around RHT were found across all WHO regions but the majority
were from in AFR and SEAR. Many interventions did not focus on a specific RHT but male and female
62
condoms featured prominently. Many interventions sought to address contextual issues such as
gender norms (often aimed at men) and the influence of individual/social group determinants,
especially beliefs and attitudes about reproductive health. Most interventions, particularly in low
income regions, adopted a dialogue-based (57%) approach; the primary target populations were
healthcare workers, and religious and influential leaders, who as part of the strategy, were
encouraged to involve local community members to bring about change.
Which interventions have been most successful?
The interventions with the largest effect estimates on uptake of RHT focused on leaders having
dialogue with their communities. Leaders included those from government, religious institutions,
and the local community (both male and female). These interventions centred on the interpretation
of local religious and cultural norms, particularly around the understanding and perceptions of men,
and sought to create an environment to support pro-RHT decision-making. At a broader contextual
level, group sessions with journalists and mass media campaigns were also used to positive effect to
support message consistency. As found for vaccine hesitancy, multicomponent interventions proved
most effective.
Which interventions have been least successful?
There are not as many examples to draw more general statements from for RHT however, the
interventions that were less successful were those that did not engage closely with the individual.
Specifically, the use of field workers instead of local opinion leaders was not as effective as
employing both in community group discussions. Familiarity and trust with the messenger seems to
be a key feature in these instances.
Objective 3. Evaluation of relevant evaluated strategies relating to vaccine hesitancy.
Of 129 studies available to potentially address the questions set out by SAGE, only 13 studies were
relevant (reporting on Outcome 1) and eligible (usable data) for inclusion in this section. Overall, of
the fifteen original PICO questions, only ten were able to be addressed, and often each had only one
study from which to draw evidence.
Thirteen studies met the inclusion criteria for evaluation using GRADE; three were cluster
randomised; three were individually randomised; four were single group cohorts and three were two
group cohorts. The process of delivering the interventions varied as did the outcomes reported.
Consequently only one outcome (two studies) for a single vaccine was pooled; meta-analysis was not
feasible for any of the other outcomes. Summary of relative risk ratios (RR) and evidence quality
(GRADE) for each question are presented in Table 2.
63
Table 2. PICO questions proposed by SAGE working group, RR (95% CI), and evidence quality
(GRADE)
Theme
PICO#
1
2
3
4
Dialoguebased
64
Question
Does the involvement of a religious leader increase
uptake of all vaccines included in primary routine
immunisation in populations with low baseline
vaccination coverage (≤50%) compared to a control
group/no intervention?
Does the involvement of a religious leader increase
uptake of all vaccines included in primary routine
immunisation in populations with high baseline
vaccination coverage (≥80%) compared to a control
group/no intervention?
Does the involvement of a traditional leader increase
uptake of all vaccines included in primary routine
immunisation in populations with low baseline
vaccination coverage (≤50%) compared to a control
group/no intervention?
Does the involvement of a traditional leader increase
uptake of all vaccines included in primary routine
immunisation in populations with high baseline
vaccination coverage (≥80%) compared to a control
group/no intervention?
Evidence
available
RR & 95%
CI
Evidence
Quality
(GRADE)
Yes
RR 4.12
(3.99, 4.26)
Very low
No
-
-
Yes
RR 4.12
(3.99, 4.26)
Very low
No
-
-
Range of
findings; RR
1.54 (1.1,
2.15) to RR
1050.00
(147.96,
7451.4)
Range of
findings; RR
2.01 (1.39,
2.93) to RR
2.38 (1.23,
4.6)
Range:
Very low
to
Moderate
5
Does social mobilisation increase uptake of all
vaccines included in primary routine immunisation by
parents in low income settings compared to a control
group/no intervention?
Yes
6
Do social media interventions increase uptake of all
vaccines included in primary routine immunisations
by parents in high income settings compared to a
control group/no intervention?
Yes
7
Do awareness raising/information provision using
mass media interventions increase uptake of all
vaccines included in primary routine immunisation by
parents in high income settings compared to a control
group/no intervention?
Yes
RR 1.57
(1.4, 1.75)
Moderate
8
Does communication tool-based health care worker
(HCW) training increase uptake of all vaccines
included in primary routine immunisation by
(rostered) patients compared to a control group/no
intervention?
Yes
Range of
findings; RR
1.54 (1.33,
1.79) to RR
3.09 (2.19,
4.36)
Range:
Low to
Moderate
Range:
Very low
to Low
9
1
Nonfinancial
incentivebased
2
3
4
1
Reminder
/recallbased
2
65
Does information-based health care worker (HCW)
training increase uptake of all vaccines included in
primary routine immunisation by (rostered) patients
compared to a control group/no intervention?
Do non-financial incentives increase uptake of all
vaccines included in primary routine immunisation in
parents compared to a control group/no
intervention?
Do non-financial incentives increase uptake of all
vaccines included in primary routine immunisation in
parents/communities located in low-income settings
compared to a control group/no intervention?
Do non-financial incentives increase uptake of all
vaccines included in primary routine immunisation in
populations targeted by vaccination campaigns
compared to a control group/no intervention?
Do non-financial incentives increase uptake of all
vaccines included in primary routine immunisation in
populations with low baseline vaccination coverage
(≤50%) compared to a control group/no intervention?
Do reminder or recall-based interventions increase
uptake of all vaccines included in primary routine
immunisation in parents or communities located in
low-income settings compared to a control group/no
intervention?
Do reminder or recall-based interventions increase
uptake of all vaccines included in primary routine
immunisation in populations with low baseline
vaccination coverage (≤50%) compared to a control
group/no intervention?
Yes
Range of
findings; RR
0.99 (0.93,
1.06) to RR
2.83 (2.6,
3.08)
Very Low
No
-
-
Yes
RR 2.16
(1.68, 2.77)
Moderate
No
-
-
No
-
-
Yes
RR 1.26
(1.13, 1.42)
Moderate
Yes
RR 3.22
(1.59 to
6.53)
Very Low
Dialogue-based interventions
Eleven studies evaluated by PICO and GRADE deployed dialogue based interventions to address
vaccine hesitancy (see definition page 7). There was appreciable variability in the quality of evidence
supporting the use of these interventions and their impact varied considerably, by type of
intervention, by vaccine and by setting.
For polio, the involvement of religious or traditional leaders in populations with low baseline uptake
indicated a large, positive effect on vaccine uptake but the evidence quality was assessed as very
low.
Five studies using social mobilisation among parents in low-income settings had a positive effect on
uptake of measles (RR 1.63 [1.39, 1.91]), DTP3 (RR 2.17 [1.8, 2.61]), DTP1 (RR 1.54 [1.1, 2.15]), and
polio (RR 1050.00 [147.96, 7451.4]) vaccines. The quality of evidence for each outcome ranged from
moderate (measles, DTP3), to low (polio) and very low (DTP1). Two studies targeting those declining
polio vaccination were associated with large increases in uptake in this population.
Two studies evaluated interventions utilising social media; these had a positive effect on uptake for
MCV4/Tdap (RR 2.01 [1.39, 2.93]) and seasonal influenza (RR 2.38 [1.23, 4.6] although respectively,
the evidence was assessed as of very low and low quality respectively.
A study utilising mass media to target parents with low levels of awareness of health services was
associated with increased uptake of all routinely recommended vaccines (RR 1.57 [1.4, 1.75]). The
quality of evidence was moderate but the effect size was not large.
The provision of communication tool-based training for health care workers had a positive impact on
uptake of EPI (RR 3.09 [2.19, 4.36]) and DTP3 (RR 1.54 [1.33, 1.79]) among rostered patients;
evidence quality was assessed as moderate and low respectively.
One study assessed the impact of information-based training for health care workers on uptake for
rostered patients, with varying results. There was little or no increase in uptake of DTP/OPV-1 (RR
0.99 [0.93, 1.06]), DTP/OPV-2 (RR 1.04 [0.97, 1.12]), BCG (RR 1.01 [0.95, 1.08]) and measles (RR 1.02
[0.96, 1.09]), a moderate increase in uptake of HepB-2 (RR 1.63 [1.49, 1.79]), HepB-3 (RR 1.89 [1.74,
2.04]) and DTP/OPV-3 (RR 1.42 [1.33, 1.51]), and a substantial increase in uptake of HepB-1 (RR 2.83
[2.6, 3.08]); but the evidence quality was very low for all.
Non-financial incentives
The evidence for non-financial incentives for parents/communities located in low-income settings
was moderate for a large, positive effect on uptake of EPI vaccines (RR 2.16 [1.68, 2.77]).
Reminder-recall interventions
Two studies assessed the impact of reminder-recall interventions on vaccine uptake in a) low income
and b) under-vaccinated populations. The impact of reminder-recall interventions in low-income
settings was positive for DTP3 (RR 1.26 [1.13, 1.42]) with moderate quality evidence. For settings
with low baseline uptake, the effects were large and positive for scheduled childhood vaccines (RR
3.22 [1.59, 6.53]) but the quality of evidence was very low.
66
Discussion
PICO & GRADE studies
All interventions were associated with increases in vaccine uptake but there are several issues that
hinder interpretation of the evidence. Interventions varied considerably in outcome impact, type of
strategy, setting and target vaccine, which makes generalisability difficult; variations in study design
further increased issues of heterogeneity. The majority of studies were observational and so we
cannot assume a causal relationship between the intervention and vaccine uptake. Two studies were
at major risk of bias and the quality of the evidence varied considerably.
Dialogue-based interventions
Despite the low quality of the evidence for the involvement of religious or traditional leaders in
populations with low baseline uptake, the strength of the intervention’s impact deserves exploration.
This intervention is important as it addresses one of the more difficult determinants of vaccine
hesitancy, namely misconceptions and community distrust. It attempts to address these using a
variety of communication and engagement channels and gives attention to all aspects of community
life that might influence vaccination decisions irrespective of age. This intervention also appears to
align itself with natural community processes – seeking out community leaders; and encouraging
dialogue across multiple levels in order to both inform and influence. In essence, the success of the
intervention could be attributed to the efforts made to seek understanding of the target audience,
facilitate open dialogue and integrate activities with familiar processes and systems.
The broad success of the social mobilisation intervention for populations refusing polio vaccination
could be attributed to the design and application of specific strategies that directly targeted this
clearly defined population. By comparison, the other two social mobilisation interventions for
measles and DTP were much less targeted. Positive outcomes associated with these interventions
appear to be due to meaningful dialogue at both the group and individual level.
The use of social media interventions showed positive effects but the quality of evidence was low to
very low. The examples suggest that this approach might work well for those who have already
started their vaccination schedule, or are familiar using such systems to organise difference aspects
of their lives. However, there is important evidence that social media is also very open to
exploitation if not managed well.
The application of mass media to target parents with low levels of awareness of health services
appears to have a valid place as an effective intervention, and whilst in the identified example,
impact is limited, there is good potential for a true positive effect across a larger population.
However, the limited impact in this case also suggests that there may be other underlying issues
affecting low impact that need investigation and subsequent tailoring of more-specific strategies in
response.
The provision of communication tool-based training for health care workers generally had a positive
effect (for EPI, DTP3) but the size of the effect and evidence quality varied. The observations about
this example and mass media suggests that interventions that adopt a unidirectional (top down)
approach to communication, may be successful among some individuals and groups, but not all;
success is dependent on the nature and degree of hesitancy.
67
The impact of information-based training for health care workers on uptake of several vaccines for
rostered patients was generally poor. A possible explanation for these results is that there was no
clear understanding of the underlying reasons for the low vaccination uptake and as such, the
intervention was not appropriately targeted. Nonetheless, the intervention did achieve good success
with Hepatitis (all doses) and DTP/OPV (dose 3); one possible reason for this is that the health
workers exhibited greater confidence but it is not clear whether this was an issue prior to the
intervention.
Non-financial incentives
The moderate to large impact of non-financial incentives for parents/communities located in lowincome settings on vaccination uptake is promising. However, in this study the target group was very
disadvantaged and as such, the food-based incentive, so closely linked with basic survival, was
unsurprisingly readily received. Furthermore, the baseline vaccination rates were very low (2%),
which suggests that this target group were underserved and more likely to show greater outcome
changes with an intervention. In this instance, it is possible that by addressing basic needs, this
intervention simultaneously built confidence and reduced vaccine hesitancy because the target
population felt that their other critical needs were being recognised, and not superseded by vaccines
alone. This symbiotic approach could be particularly important for more marginalised groups.
Reminder-recall interventions
Although positive, the relatively low observed impact of reminder-recall interventions in low-income
settings seems to reflect the limitations of using this kind of intervention in isolation. In this
example, a complex set of issues was identified in the target population but the intervention only
addressed one of them. Reminder-recall on its own is clearly not enough to tackle contexts where
there are multiple determinants at play.
Overall completeness and applicability of evidence
Despite the low number of studies, there is some opportunity to be moderately confident in several
of the interventions including: social mobilisation, mass media, communication tool-based training
for HCW, non-financial incentives, and reminder-recall activities. However, none of these
interventions were without shortcomings, and given the additional caveats around indirectness and
the variability in content, setting, delivery method, target population composition and effect
estimates across outcomes, the success, and potential application, of these interventions must be
cautiously considered when looking to deliver them in different circumstances.
68
Objective 4. Synthesis of findings
Overall this review has found that there are 1) few existing strategies that have been explicitly
designed to address vaccine hesitancy; and 2) even fewer strategies that have been evaluated for
impact. The first of these issues is most likely because ‘vaccine hesitancy’ is an emerging issue, which
to date, has not had a clear definition from which to explore and interrelate identified concerns. As
such, interventions are often only half-conceived; target audiences are not always appropriately
identified, and there is a lack of rigorous understanding of the actual problem. Interventions around
polio vaccination are the exception to this – and the findings of this review indicate their greater
success as a result.
At present, the efforts that have been made to address issues of hesitancy are disparate. This is not
surprising given the complexity of the problem but it does make interpretation of the evidence more
difficult. Specifically, while a number of interventions did have a positive impact, it was variable.
Wide variation was observed in the effect size between studies, settings and target populations. Even
within studies there was wide variation on the impact on uptake of specific vaccines. In addition,
the high level of heterogeneity across study design and outcomes coupled with few available studies
further limited our ability to draw many general conclusions about the effectiveness of different
strategies.
Nonetheless, across the literature, interventions that are multicomponent and/or have a focus on
dialogue-based approaches tend to perform better. This message is corroborated by the more
formal GRADE assessment of the evidence which indicated greater quality of evidence for social
mobilisation, mass media and communication tool-based training for HCW. Together, these
interventions suggest that taking a comprehensive approach that targets multiple audiences and
layers of social interaction are more likely to bring positive results. The evidence for the other
interventions, non-financial incentives and reminder-recall activities, was also of good quality, and
carries the potential to bring positive change by addressing the more practical aspects of vaccination.
It is important to reiterate however, that the key to success seems to lie in designing more complex,
but integrated, multi-component interventions.
This review shows that vaccine hesitancy is a complex issue and no single strategy will be able to
address it single-handedly. There are some promising examples, but many are incomplete and most
are not directly comparable. Perhaps one of the greatest drawbacks of the interventions identified is
that so many operate from an assumption-based rather than an evidence-based approach;
appropriate evaluation is also lacking. On a more positive note, there is a growing body of research
on the determinants of vaccine hesitancy which can help inform and refine currently used
approaches that look promising but have not yet been fully implemented nor evaluated, as well as
supporting the formative research, design and evaluation of new interventions. This is an
opportunity to develop early learnings and set the precedent to advance the understanding and
management of issues of vaccine hesitancy.
Limitations
This review may be subject to publication bias, in that unsuccessful interventions may be less likely to
be documented in either the peer-reviewed or grey literature. Consequently, although the review
gives some indication of interventions that successfully reduced vaccine hesitancy in specific
populations and settings, interventions that were found to have no effect or a negative effect may be
under-represented.
69
Conclusions and implications
Literature identified
•
Despite extensive literature searches, only 14% (166/1149) of the peer-reviewed studies and
25% (15/59) of the grey literature, discussed evaluated interventions relating to vaccine
hesitancy; the bulk of the literature originated from AMR and EUR.
•
Across all regions and literature, the majority of interventions were multi-component in
nature, followed by dialogue-based approaches (except EMR which only featured multicomponent). Reminder-recall interventions featured only in higher-income regions (AMR,
EUR, WPR), and incentives appeared only in AMR and AFR.
Interventions – which were successful and which were not?
70
•
Whilst several approaches taken independently can be successful, the most effective
interventions employed a number of strategies (multi-component interventions) to increase
vaccine uptake, knowledge and awareness, and shift attitudes towards pro-vaccination. The
most promising strategies for Outcome 1 (vaccination uptake) included (in no particular
order): 1) directly target unvaccinated or under-vaccinated populations; 2) aim to increase
knowledge and awareness surrounding vaccination; 3) improve convenience and access to
vaccination; 4) target specific populations such as the local community and HCW; 5) mandate
vaccinations or impose some type of sanction for non-vaccination; 5) employ reminder and
follow-up; and 6) engage religious or other influential leaders to promote vaccination in the
community. For Outcome 2 (psychological shift), the introduction of education initiatives,
particularly those that embed new knowledge into a more tangible process (e.g., hospital
procedures, individual action plans), were most successful at increasing knowledge and
awareness and changing attitudes.
•
Consistent with the above and notwithstanding the small number of studies, the GRADE
approach yielded evidence in which there is moderate confidence for several types of
interventions including: social mobilisation, mass media, communication tool-based training
for HCW, non-financial incentives, and reminder-recall activities. However, all studies had
weaknesses and strategies should be carefully considered before adopting them in different
settings.
•
Review of the interventions adopted to address hesitancy around RHT showed an important
parallel with those for vaccine hesitancy. Specifically, dialogue-based interventions,
particularly those incorporating a focus on community engagement/social mobilisation and
the improvement of HCW communication, were most effective for improved uptake.
•
Interventions that were single-component did not work as well as those that were multicomponent. Also, interventions that were the most passive (e.g., posters, radio
announcements, websites and media releases) that did not have an additional engagement
component were less effective. It is possible that there are more examples of interventions
that have failed in the field but these receive little attention in the literature; identification of
and lessons from these experiences will need to be explored through different means.
Opportunities
•
Despite the large body of literature on the many determinants of vaccine hesitancy, most
interventions have focused on individual level issues (e.g., knowledge, awareness) and
vaccine/vaccination specific concerns (e.g., mode of delivery, role of healthcare
professionals). There needs to be more attention given to understanding and addressing
hesitancy at the community level (e.g. social norms).
•
There is an opportunity to broaden the outcomes of interest when assessing the effects of
interventions, in particular, more intermediary outcomes such as changes in knowledge,
norms, attitude and awareness. These outcomes might indicate important shifts along the
vaccine continuum, either away from or towards acceptance, even if they do not necessarily
lead to a change in vaccination uptake. Appreciating where individuals and communities lie
on the continuum and what defines this offers another insight to inform intervention design.
Limitations
•
The term/concept of ‘vaccine hesitancy’ has only recently been coined and has not yet found
general currency among researchers or immunisation professionals. To overcome this issue,
the SAGE WG Model of determinants of Vaccine Hesitancy was used as a default coding tool
whereby only those studies that reported on interventions to address one or more of the
determinants were included. Studies that reported on strategies that impacted on
vaccination uptake in general were excluded (such as system or supply issues).
•
Another reason for the paucity of relevant studies is that the questions emphasise specific,
single component strategies, but many evaluated strategies are neither designed nor
presented in this way. Evaluated, multi-component interventions were identified but only
overall impact data were presented and VH data was not separately available.
Key lessons
71
•
Vaccine hesitancy is complex and dynamic; future strategies need to reflect and address
these complexities in both design and evaluation. In the first instance, implementers must
adequately identify the target population and understand the true nature of their particular
vaccine and/or vaccination concerns; this will help ensure a well-informed intervention.
•
Well integrated, multi-component strategies should be promoted and must be accompanied
by an appropriate evaluation process. Specifically, implementers must be able to appreciate
the influence of individual components which will benefit the immediate operations and the
design of future interventions.
•
Overall, the design and delivery of interventions should try to reflect the following points: 1)
Target audiences should be clearly identified and specific issues well researched and
understood; 2) Interventions should focus on meaningful engagement (i.e., dialogue-based,
social mobilisation) that supports realistic action; 3) Contextual influences, from the
individual through to the health system, should be acknowledged and accounted for when
choosing strategies; 4) Interventions should be multi-component and seek to address
primary determinants of uptake across the different domains of influence; 5) Interventions
must be evaluated.
Appendix A6A.2 Strategies to address vaccine hesitancy: summary of
published literature reviews*:
* Table A6.1 presents Main conclusions of published literature reviews and
meta-analysis on strategies to address vaccine hesitancy (2006 to 2014)
72
Table A6.1 Main conclusions of published literature reviews and meta-analysis on strategies to address vaccine hesitancy (2006 to
2014)
Increasing Appropriate Vaccination, The Community Guide[14]
Recommended interventions to increase Community Demand for
Vaccinations:
• Client or family incentive rewards.
• Reminder and recall interventions.
• Community-based interventions implemented in combination.
• Vaccination requirements for child care, school, and college
attendance.
Recommended Provider- or System-based Interventions
• Health Care system-Based Interventions Implemented in
Combination.
• Immunization Information Systems.
• Assessment and feedback for vaccination providers.
• Provider Reminders
• Standing Orders.
There is insufficient evidence to determine the effectiveness
of:
• Client-held Paper Immunization Records.
• Clinic-Based Education when Used Alone.
• Community-Wide Education when Used Alone.
• Monetary Sanction Policies.
There is insufficient evidence to determine the effectiveness
of:
− Provider Education when Used Alone.
What are the factors that contribute to parental vaccine-hesitancy and what can we do about it?, Williams S.E., 2014 [1]
Current data does not support one method for intervention as superiorly effective over others.
- Vaccine decision-making for vaccine-hesitant families is complex and this contributes to the lack of evidence for effective
interventions.
- Most reported interventions are primarily educational and few interventions have evaluated the ultimate outcome: on-time
vaccination.
Cultural tailoring and message framing of interventions have been used successfully in conjunction with educational material for
vaccine-hesitant parents.
A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy, Sadaf, A., 2013 [4]
The review did not reveal any convincing evidence on effective interventions to address parental vaccine hesitancy and refusal.
- Main evaluated interventions were: reminder/recall systems; educational interventions; incentives and government and school
immunization policies.
- Few intervention studies measured outcomes linked to vaccine refusal (vaccination rates in refusing parents, intent to vaccinate, or
73
-
change in attitudes).
Most studies evaluating the impact of parent-centered information or education reported a statistically significant improvement on
parents’ intentions to vaccinate their children. However, parents’ attitude changes were inconsistent.
Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology, Glenton, C., 2011 [5]
- Evidence was of low quality for LHWs promoting immunization uptake among families in LMICs.
- However, the LHW programme increased the number of children whose DPT and measles immunizations were up to date
Interventions for improving coverage of child immunization in low- and middle-income countries, Oyo-Ita, A., 2011 [9]
Home visits and health education may improve immunization coverage but the quality of evidence is low.
- There was low quality evidence that: facility based health education may improve the uptake of DPT3 coverage; and also that a
combination of facility based health education and redesigned immunization cards may improve DPT3 coverage.
- There was also moderate quality evidence that: evidence-based discussions, and that information campaigns increase uptake of at
least a dose of a vaccine.
Too little but not too late: Results of a literature review to improve routine immunization programs in developing countries, Ryman, T.K.
2008 [10]
Few papers were identified and fewer were of strong scientific quality.
- The strategies to “bring immunizations closer to the community” (including non-health workers to encourage people to seek
immunization services, bringing immunization services to communities, and increasing demand through educating communities)
could improve childhood vaccine uptake.
- Use of home visits for education and/or immunization service delivery may increase childhood vaccine uptake.
Increasing the demand for childhood vaccination in developing countries: a systematic review, Shea, B., 2009 [11]
Most studies reviewed represented a low level of evidence.
− Interventions with an impact on vaccination uptake included knowledge translation (KT) (mass media, village resource rooms and
community discussions) and non-KT initiatives (incentives, economic empowerment, household visits by extension workers). Most
claimed to increase vaccine coverage by 20 to 30%.
− Mass media campaigns may be effective, but the impact depends on access to media and may be costly if run at a local level. The
persistence of positive effects has not been evaluated.
Educational interventions to increase HPV vaccination acceptance: A systematic review, Fu, L.Y., 2014 [6]
No strong evidence to recommend any specific educational intervention for wide-spread implementation.
− Well-designed studies adequately powered to detect change in vaccine uptake were rare and generally did not demonstrate
effectiveness of the tested interventions. Few studies used the outcome of HPV uptake.
74
Systematic literature review of the evidence for effective NIS promotional communications, Cairns, G., 2012 [7]
There is good evidence that a range of promotional communications can positively change knowledge, attitudes and behaviours.
− Interventions aiming to promote more favorable attitudes to immunization did not report success. Interventions aiming to improve
knowledge levels did report success, but did not demonstrate any positive effects on vaccine uptake / intention.
− Many interventions combined communication channels and methods, so it is not possible to identify which types of communication
initiatives are most effective. Many interventions included structural change to make immunizations more accessible, so it is not
possible to determine the net contribution of communications.
Face to face interventions for informing or educating parents about early childhood vaccination, Kaufman, J., 2012 [8]
The limited evidence available is low quality and suggests that face to face interventions to inform or educate parents about
childhood vaccination have little to no impact on immunization status, or knowledge or understanding of vaccination.
− Communication about vaccination should be incorporated into a healthcare encounter, rather as separate activities
Strategies to improve vaccination uptake in Australia, a systematic review of types and effectiveness, Ward, K., 2012 [3]
The most effective and common strategies for increasing community demand and provider based interventions were patient
reminder/recalls and provider reminders.
− Education for the public and providers (alone or as part of multicomponent strategy) had variable impact on uptake.
− Other effective strategies in target groups / for specific vaccines: integration of vaccination status checks into routine health
assessments, individual provider support, and targeted promotion campaigns in the mass media.
Primary care strategies to improve childhood immunization uptake in developed countries: systematic review, Williams, N., 2011 [2]
− Strategies with positive effect on immunization uptake : parental reminders, provider reminder/recall strategies, provider education
and provider feedback, multicomponent interventions (insufficient evidence to distinguish which component of the intervention has
had the greatest effect on immunization rates)
− Insufficient evidence on the effect of parental education interventions on parental behavior.
75
Strategies to address vaccine hesitancy: summary of published literature reviews:
Review by Eve Dube, Institut national de santé publique du Québec (INSPQ), Québec (Québec), G1E
7G9, Canada
Since 2006, 11 literature reviews or meta-analysis on strategies to increase vaccine uptake or vaccine
acceptance in the public or among health care providers have been published.[1-11] Only 2 of these reviews
were directly targeting strategies to address vaccine hesitancy (defined as voluntary refusal or delay of
recommended childhood vaccines while vaccination services are available).[1, 4] In addition, in collaboration
with the US Centers for Disease Control and Prevention the Community Guide3 also regularly publishes
evidence-based recommendations on interventions intended to improve routine delivery of universally
recommended vaccinations in the United States, based on a logic framework that has been described by
Briss and collaborators in 2000.[12] Table 1 presents a summary of the published literature reviews and a
meta-analysis on strategies to increase vaccine uptake or vaccine acceptance.
Additionally, on behalf of the Working Group, the London School of Hygiene and Tropical Medicine
(LSHTM) conducted a literature review to identify individual studies that have been implemented across
diverse global contexts in an effort to respond to, and manage, issues of vaccine hesitancy.[See
Appendix][add ref] Of the 1149 primary studies that were identified, only 166 provided information on
evaluated interventions and even fewer were directly targeting vaccine hesitant individuals.
Looking at the literature, there is no strong evidence to recommend any specific intervention to address
vaccine hesitancy or refusal. The reviewed studies included interventions of diverse content and approaches
implemented in different settings and targeting various populations. The number of interventions similar
enough to be grouped was often low and insufficient to demonstrate effectiveness using recognized
validation criteria [www.cochrane-handbook.orgeditors].[13] In addition, many of the reviewed studies were
conducted in the United States and few were from LMIC, which further limits global generalizability of the
findings. The high quality studies that were reviewed were mostly single-component interventions (often
educational interventions) that are less challenging to evaluate than multi-component interventions or
interventions aiming to change determinants that are difficult to measure (such as social norms). Finally, few
studies included in the reviews used vaccine uptake or on-time vaccination as an outcome and even fewer
studies directly targeted vaccine hesitant patients.
While acknowledging these caveats, findings indicate that reminders and recall for patients and health care
providers are effective means of improving vaccine uptake among various groups and in different settings.[2,
3, 14]
However, there is limited evidence on the effectiveness of reminders and recalls for vaccine-hesitant
patients.[15, 16] There is mixed evidence on the effectiveness of face-to-face communication interventions,
health care providers training interventions, community-based interventions and communication
interventions using mass media. For instance, many communication tools aimed at helping health care
3
The Community Guide is a website that houses the official collection of all Community Preventive Services Task
Force findings and the systematic reviews on which they are based. Available online: Guide to Community Preventive
Services. Increasing appropriate vaccination: www.thecommunityguide.org/vaccines/index.html. Last updated:
06/12/2014. Page Accessed: 06/25/2014.
76
provider discussions with vaccine-hesitant parents have been published,[17-21] but few have been evaluated.
Whereas communication frameworks often suggest discussing vaccines in a participatory and open manner,
a 2013 study by Opel, et al. found that more directive, presumptive discussion styles might be more effective
to improve vaccine acceptance in the middle to upper class vaccine hesitant Seattle population studied .[22] In
addition, interventions using mass media, including the internet, are challenging to evaluate and are not
well-suited to experimental design; other type of evaluations are subject to various bias due to the many
potential confounding factors which limits the quality of the evidence available.
Nevertheless, key principles to optimize the development of strategies to address vaccine hesitancy can be
identified when looking at the literature. To be effective, interventions should be developed using a planning
framework, such as the TIP toolkit ( See Section 5), and should be based on a theoretical model.[7] The use
of a combination of different interventions (multiple-components) appears to be more effective than singlecomponent intervention.[2, 14, 23] Interventions are most likely to succeed when they are based on empirical
data and situational assessment – both to have a detailed level of understanding of the vaccine hesitancy
situation (susceptible populations, key determinants of vaccination, barriers and enabling conditions, etc.)
than to properly evaluate the impact of the intervention.[7, 24] Finally, the development of culturally-tailored
and personalized interventions have shown to be effective to enhance compliance to preventive behaviors,
including vaccination.[4, 25-27]
77
Table 1.Summary of published literature reviews and meta-analysis on strategies to address vaccine hesitancy (2006 to 2014)
Title/ First author/
year of publication
Increasing
Appropriate
Vaccination, The
Community
Guide[14]
78
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
Inclusion:
Interventions
addressing
universally
recommended
adult, adolescent,
or childhood
To presents
vaccinations
the results of
Primary study
systematic
reviews of the Take place in HIC
Be written in
effectiveness,
English
applicability,
Meet the evidence
other effects,
review and Guide
economic
chapter
impact, and
barriers to use development
team’s definition
of selected
of the
populationinterventions
based
Provide
interventions
information on one
intended to
or more outcomes
improve
related to the
vaccination
analytic
coverage in
frameworks
HIC
Compare a group
of persons who
had been exposed
to the intervention
with a group who
had not been
Main
outcome
measure
Vaccine
uptake
Nb of
studies
included
Quality
assessment
of studies
From 2 to
240
depending
on the
Reported
type of
interventi
ons
Main conclusions
Interventions to increase Community Demand for Vaccinations
The Community Preventive Services Task Force recommends:
Client or family incentive rewards based on sufficient
evidence of effectiveness in increasing vaccination rates in
children and adults (based on results from six studies that
evaluated incentive awards alone or in combination with
additional interventions).
Reminder and recall interventions based on strong evidence
of effectiveness in improving vaccination coverage in children
and adults, in a range of settings and populations, when
applied at different levels of scale from individual practice
settings to entire communities, across a range of intervention
characteristics, when used alone or with additional components
(62 studies).
Community-based interventions implemented in
combination (to enhance access to vaccination services,
increase community demand, and reduce missed opportunities
by vaccination providers) to increase vaccinations in targeted
populations, on the basis of strong evidence of effectiveness in
increasing vaccination rates (17 studies).
Vaccination requirements for child care, school, and
college attendance based on strong evidence of effectiveness
in increasing vaccination rates and in decreasing rates of
vaccine-preventable disease and associated morbidity and
mortality, based on findings from 27 studies demonstrating
effectiveness of vaccination requirements: for attendance in a
variety of settings; for an array of recommended vaccine; in
populations ranging in age from early childhood to late
adolescence.
There is insufficient evidence to determine the effectiveness of:
Client-held Paper Immunization Records (7 studies)
Title/ First author/
year of publication
What are the
factors that
contribute to
parental vaccinehesitancy and what
79
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
exposed or who
had been less
exposed.
To review the
known barriers
to vaccination
reported by
vaccine-
Inclusion:
Intervention
specifically
targeting vaccinehesitant (VH)
Main
outcome
measure
Attitudes,
vaccination
intent or
vaccine
uptake of
Nb of
studies
included
Quality
assessment
of studies
15
(7 on
childhood
vaccines
Not
reported
Main conclusions
Clinic-Based Education when Used Alone (4 studies)
Community-Wide Education when Used Alone (6 studies)
Monetary Sanction Policies (2 studies)
Provider- or System-based Interventions
The Community Preventive Services Task Force recommends:
Health Care system-Based Interventions Implemented in
Combination on the basis of strong evidence of effectiveness
in increasing vaccination rates in targeted client populations
(62 studies).
Immunization Information Systems on the basis of strong
evidence of effectiveness in increasing vaccination rates (240
studies)
Assessment and feedback for vaccination providers based
on strong evidence of their effectiveness in improving
vaccination coverage in children and adults, alone or in
combination with additional interventions, in a variety of
settings and populations (33 studies).
Provider Reminders based on strong evidence of
effectiveness in improving vaccination coverage in adults,
adolescents, and children; when used alone or with additional
components; across a range of intervention characteristics; and
in a range of settings and populations (48 studies)
Standing Orders based on strong evidence of effectiveness in
improving vaccination rates in children and adults, alone or in
combination with additional interventions, in a variety of
settings and populations (40 studies).
There is insufficient evidence to determine the effectiveness of:
Provider Education when Used Alone (5 studies).
Current data does not support one method for intervention as
superiorly effective over others.
Few interventions have evaluated the ultimate outcome: ontime vaccination of infants or children.
Most reported interventions are primarily educational in
Title/ First author/
year of publication
can we do about
it?, Williams S.E.,
2014 [1]
A systematic
review of
interventions for
reducing parental
vaccine refusal and
vaccine hesitancy,
Sadaf, A., 2013 [4]
80
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
hesitant
parents or
parents and the healthcare
current
providers working
evidence on
with VH parents
strategies to
Quantitative
evaluation of
address
improvement
parental
vaccine
Published between
hesitancy /
2003-2013
HIC
English language
Exclusion:
Qualitative studies
Interventions not
focusing on
vaccines
recommended by
ACIP
Inclusion:
Primary reports of
To evaluate
intervention
the literature
studies
on
Quantitative
interventions
outcome measures
to decrease
(vaccine refusal,
parental
behavior, attitudes
vaccine refusal
and/or intent to
and hesitancy
vaccinate)
toward
Published between
recommended
1990-July 2012
childhood and
English language
adolescent
Exclusion:
vaccines
Non-intervention
studies, reviews,
Main
outcome
measure
children
Parental
vaccine
refusal
behavior,
attitudes
toward
immunizati
on, and/or
intent to
vaccinate
Nb of
studies
included
Quality
assessment
of studies
and 8 on
HPV
vaccine)
30
(25 from
USA)
Main conclusions
nature, yet the decision-making process for vaccine-hesitant
families is likely very complex and influenced by factors
which are difficult to measure, such as influences by social
networks. This complexity likely contributes to the lack of
evidence for effective interventions.
Cultural tailoring and message framing of interventions have
been used successfully in conjunction with educational
material for VHPs.
Use of a theoretical model to provide a framework for
development of intervention is often recommended; however,
few of the studies identified in this review did use a theoretical
model.
Reported
(most
studies
scored low
on GRADE
criteria)
Most studies (13) used a before-after intervention design and
the remaining were RCTs (3), NRCTs(7) and evaluation
studies (6).
The review did not reveal any convincing evidence on
effective interventions to address parental vaccine hesitancy
and refusal.
Large number of studies evaluated interventions for increasing
immunization coverage rates such as the use of reminder/recall
systems, parent, community-wide, and provider-based
education and incentives as well as the effect of government
and school immunization policies.
Few intervention studies measured outcomes linked to vaccine
refusal such as vaccination rates in refusing parents, intent to
vaccinate, or change in attitudes toward vaccines.
Most studies evaluating the impact of parent-centered
information or education reported a statistically significant
Title/ First author/
year of publication
Can lay health
workers increase
the uptake of
childhood
immunisation?
Systematic review
and typology,
Glenton, C., 2011
[5]
81
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
historical articles,
case reports,
commentaries,
clinical guidelines
and
recommendations
Inclusion:
Randomized
controlled trials
(RCTs), nonrandomized
controlled trials
(NRCTs),
interrupted-timeseries (ITS)
studies, controlled
To assess the
before–after
effects of lay
studies and studies
health workers
where the
(LHWs)
intervention’s aim
interventions
was to increase
on childhood
immunization
immunization
coverage among
uptake
children <5 years
of age
Any intervention
delivered by
LHWs which
aimed to increase
childhood
immunization
coverage
Studies where
Main
outcome
measure
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
improvement on parents’ intentions to vaccinate their children.
However, data for parents’ attitude changes were very
inconsistent and so offered limited insight.
Immunizati
on
coverage
12
(7 in HIC) Reported
In six studies, LHWs promoted immunization uptake among
economically disadvantaged families in high-income countries.
The LHW programmes increased the number of children
whose immunizations were up to date. This evidence was of
moderate quality.
Evidence was of low quality for LHWs promoting
immunization uptake among families in LMICs (However, the
LHW programme increased the number of children whose
DPT and measles immunizations were up to date)
The quality of the evidence was very low for the impact of
vaccines given by the LHWs. In two studies, LHWs increased
the number of children whose immunizations were up to date
compared with standard care. However, it is unclear whether
these differences were statistically significant.
Title/ First author/
year of publication
Interventions for
improving
coverage of child
immunization in
low- and middleincome countries,
Oyo-Ita, A., 2011
[9]
82
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
LHWs were used
as a substitute for
trained health
professionals or in
addition to health
professionals
Published until
February 2009
Exclusion:
Studies based
outside of primary
health care, such
as in hospitals or
schools
Inclusion:
RCTs, NRCTs,
and ITS studies
Interventions
targeting children
To evaluate
aged 0 to 4 years,
the
caregivers, and
effectiveness
of intervention health providers
Comparisons with
strategies to
routine
boost and
immunization
sustain high
childhood
practices in the
immunization
study setting or
coverage in
with different
LMIC
interventions or
similar
interventions
implemented with
different degrees
Main
outcome
measure
Proportion
of target
population
fully
immunized
with
recommend
ed
vaccines,
by age
Number of
children
aged two
years fully
immunized
per vaccine
Nb of
studies
included
6
(5 cluster
RCTs)
Quality
assessment
of studies
Main conclusions
Reported
(4 studies
at high risk
of bias)
Moderate quality evidence:
Evidence-based discussions probably improve DPT3 and
measles coverage
Information campaigns probably increase uptake of at least a
dose of a vaccine.
Low quality evidence:
Facility based health education alone or in combination with
redesigned immunization cards may improve the uptake of
combined vaccine against diphtheria, pertussis, and tetanus
(DPT3) coverage.
One study suggests that this monetary incentive may lead to
little or no difference in the uptake of MMR or DPT1.
Training of immunization managers to provide supportive
supervision for health providers was assessed by one study and
may improve the uptake for DPT3, OPV3, and hepatitisB3.
Home visits may improve OPV3 and measles coverage.
A combination of monetary incentives (patient oriented);
quality assurance (provider oriented); and provision of
equipment, drugs and materials (health system oriented)
Title/ First author/
year of publication
Too little but not
too late: Results of
a literature review
to improve
routine
immunization
programs in
developing
countries, Ryman,
T.K. 2008 [10]
83
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
of intensity
Published until
2010 except 2011
in the case of the
MEDLINE search
Exclusion:
Patient reminder
and recall as this is
covered in an
existing review
[28]
Controlled beforeand-after studies
that had only two
study locations
To identify
strategies
used to
increase
routine
immunization
programs
Inclusion:
Studies published
in English, French,
or Spanish from
1975 through 2004
Primary data on
effectiveness of
the strategy was
not required for
inclusion, as the
goal was to
identify all
possible strategies
Exclusion:
Studies with low
quality scores
Main
outcome
measure
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
interventions was evaluated in another arm of a study. The
study suggests that this intervention may lead to little or no
difference in MMR.
Percentage
change in
fully
vaccinated
children
(FVC),
percentage
change in
vaccination
coverage
for specific
antigens,
dropout
from
routine
immunizati
ons, or
timeliness
Reported
25
(studies
with a
score <60
were
excluded)
Few papers were identified and in particular, few papers were of
strong scientific quality.
The strategies to “bring immunizations closer to the community”
(including non-health workers to encourage people to seek
immunization services, bringing immunization services to
communities, and increasing demand through educating communities)
could improve the percentage of FVC.
Use of home visits for education and/or immunization service
delivery may increase in the percentage of FVC.
Conflict areas are generally difficult to reach because of security
concerns. Three papers evaluated strategies that provided
immunizations in conflict areas. Strategies involved using bush planes
to gain access to people, providing incentives to attract people to
immunization sites, going house-to-house to motivate parents to bring
their children for immunization, and working with communities to
coordinate provision of services.
Title/ First author/
year of publication
Increasing the
demand for
childhood
vaccination in
developing
countries: a
systematic review,
Shea, B., 2009 [11]
Educational
interventions to
84
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
To review
literature on
efforts to
stimulate
demand for
routine
childhood
vaccination.
To summarize
and evaluate
Inclusion:
Studies providing
a description of
activities that
seemed designed
to increase
demand for
childhood
vaccination
Studies that
provided
quantitative
estimates of the
impact of
interventions.
Published up to
September 2008
and searched for
primary studies
published since
2004
Exclusion:
Studies of
exclusively supply
side initiatives
Studies from
developed
countries
Inclusion:
RCTs, NRCTs as
Main
outcome
measure
of
vaccination
Nb of
studies
included
Quality
assessment
of studies
Uptake of
routine
childhood
vaccines
8
Reported
Receipt of
HPV
33
Reported
Main conclusions
Most studies reviewed represented a low level of evidence.
Interventions with an impact on vaccination uptake included
knowledge translation (KT) (mass media, village resource rooms and
community discussions) and non-KT initiatives (incentives, economic
empowerment, household visits by extension workers).
Most claimed to increase vaccine coverage by 20 to 30%. Estimates
of the cost per vaccinated child varied considerably with several in the
range of $10-20 per vaccinated child.
Mass media campaigns may be effective, but the impact depends on
access to media and may be costly if run at a local level. The
persistence of positive effects has not been evaluated.
Most studies involved populations with higher educational
attainment and most interventions required participants to be literate.
Title/ First author/
year of publication
increase HPV
vaccination
acceptance: A
systematic review,
Fu, L.Y., 2014 [6]
85
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
the evidence
well as quasifor educational experimental
interventions
designs
to increase
HPV vaccine
HPV
acceptance in
vaccination
patients eligible to
acceptance
receive the
vaccine, or their
parents
Presented
educational
interventions and
measured the
following
outcomes were
included: (1)
receipt of HPV
vaccine (any dose
or completion of
the3-dose series),
(2) intention to
receive HPV
vaccine, or (3)
attitude toward
HPV vaccine
Published
between1946 to
August 20, 2013
English language
Exclusion:
Pilot or descriptive
projects which
reported only
Main
outcome
measure
vaccine,
intention to
receive
HPV
vaccine,
attitude
toward
HPV
vaccine
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
The minority of studies used the outcome of HPV uptake.
Well-designed studies adequately powered to detect change in
vaccine uptake were rare and generally did not demonstrate
effectiveness of the tested interventions.
There is no strong evidence to recommend any specific educational
intervention for wide-spread implementation.
Title/ First author/
year of publication
Systematic
literature review of
the evidence for
effective NIS
promotional
communications,
Cairns, G., 2012 [7]
86
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
qualitative or
anecdotal results
Studies that did
not focus primarily
on populations
eligible to receive
HPV vaccine or
their parents or
that did not subset
results in a way
that the authors
were able to
extract
information on
these target groups
To examine
Inclusion:
the
All included
effectiveness
studies reported
of national
evaluation,
immunization
experimental,
schedule
quasipromotional
experimental, or
communicatio interrupted time
ns in European series data on
context
vaccine-uptake or
likely behavioral
precursors
Experimental and
pilot studies of
communications
promoting
nationally
scheduled
Main
outcome
measure
Change in
measured
immunisati
on uptake
rates
Secondary
outcomes
included
measured
changes in
the target
audience’s
knowledge,
attitudes
and other
behavioural
determinant
Nb of
studies
included
Quality
assessment
of studies
33
(22 on
interventi
ons
promoting Reported
influenza
vaccinatio
n, 11 on
childhood
vaccines)
Main conclusions
Fifteen of the 33 evaluation studies captured in the review were rated
as high validity studies on the basis of the quality, validity and
applicability appraisal process. Seven high scoring studies reported
convincing evidence of positive effect and eight reported no
evidence of effectiveness. Interventions that included an aim to
promote more favorable attitudes to immunization did not report any
evidence of more pro-immunization attitudes. The review found that
interventions aiming to improve knowledge levels were usually
successful, but did not demonstrate any positive effects on vaccine
uptake or intention to be vaccinated.
Some interventions that aimed to improve knowledge levels of
healthcare workers through education and training did report
evidence of improved rates of vaccine uptake.
There is good evidence that a range of promotional communications
can positively change knowledge, attitudes and behaviors. The
evidence for increased immunization uptake is particularly
promising for health care workers, patient risk groups (including the
elderly), and seasonal flu vaccine promotions. However many of the
Title/ First author/
year of publication
Face to face
interventions for
informing or
educating parents
about early
childhood
vaccination,
Kaufman, J., 2012
[8]
87
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
vaccination were
also eligible for
inclusion
European
countries and their
territories
English and nonEnglish language
Academic and
grey literature
Published from
2000 to 2011
Exclusion:
Off topic
Not a primary
study
To assess the
Inclusion:
effects of face
RCTs and cluster
to face
RCTs .This review
interventions
focuses on face to
for informing
face single or
or educating
combined
parents about
interventions to
early
inform or educate
childhood
(oral presentations,
vaccination on one on one or
immunization
group classes or
uptake and
seminars,
parental
information
knowledge
sessions, or home
outreach visits).
- Published until
2012
Main
outcome
measure
s
Primary
outcomes
are
immunisati
on status of
child and
parents’
knowledge
or
understandi
ng of
vaccination
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
interventions captured by the review combined communication
channels and methods, so it is not possible to identify which types of
communication initiatives are most effective, or to estimate their
contribution to overall intervention effect. In addition, many
interventions included structural change to make immunizations
more accessible (e.g. reduced cost, more accessible clinics), further
complicating attempts to determine the net contribution of
communications.
7
(6 RCTS
and 1
cluster
RCT – 3
LMIC, 4
HIC)
Reported
The overall result is uncertain because the individual studyresults
ranged from no evidence of effect to a significant increase in
immunization.
Three studies reported immunization status measured 3 months after a
single-session intervention. Effect of the intervention remains
uncertain. Four comparisons from these studies showed inconsistent
results (studies with higher risk of bias were associated with greater
increase in immunization, compared with control, while study with
lower risk of bias showed no or little evidence of effect. The quality
of evidence was low.
Results for interventions where immunization status was measured at
the conclusion of a multi-session intervention indicated a very
uncertain effect with statistically insignificant effect ranging from
reduced to no evidence effect, and had wide confidence intervals. The
quality of evidence was very low.
Effect was also very uncertain for studies measuring knowledge or
understanding of vaccination. The two multi-session interventions
Title/ First author/
year of publication
Strategies to
improve
vaccination uptake
in Australia,
a systematic review
of types and
effectiveness,
Ward, K., 2012 [3]
88
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
Exclusion:
Interventions
directed to
communities
To profile and Inclusion:
critique
Published from
available
1997 through to
evidence of
May 2011
strategies to
English language
improve
Studies must have
vaccination
reported original
uptake in
research about, or
Australia and
evaluation of, one
evaluate their
or more
effectiveness
interventions to
improve uptake of
one or more
vaccines available
in Australia.
Studies must have
included a
quantitative
measure of uptake
as a primary
outcome
Exclusion:
Studies describing
uptake in the
absence of an
intervention or
reporting only
other outcomes
(i.e. descriptive or
Main
outcome
measure
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
showed non-significant increases in knowledge scores compared with
control. The quality of evidence was very low.
Vaccine
uptake
49
Reported
The most effective and common strategies for increasing community
demand and provider based interventions were patient
reminder/recalls and provider reminders. Education for the public and
providers (either alone or as part of a multicomponent strategy) had
variable impact on uptake, with increases less substantial or direct
when compared with reminder/recalls.
Also effective were integration of vaccination status checks into
routine health assessments, individual provider support, and targeted
promotion campaigns in the mass media, although studies of these
interventions were minimal and confined to particular target groups
and vaccines.
For enhancing access, catch-up plans for those overdue for
vaccination were particularly effective, often reducing the percentage
of those overdue by more than 50%. The two studies involving an
accelerated vaccination schedule for hepatitis B showed an increase in
the overall completion rate compared with the standard schedule.
Results from the few studies of home visits for routine childhood
vaccination highlighted their effectiveness, particularly when
targeting Aboriginal and Torres Strait Islander children. The same
effectiveness was observed for expanding access in hospitals and
vaccination clinics in public settings.
There were several effective regulatory interventions that were
beyond ‘baseline practice’ of funding vaccines on the NIP and schoolbased vaccination programs. These included national parental
incentives; the maternity immunization allowance (MIA) and linking
vaccination to the child care benefit as well as a jurisdictional
hepatitis B vaccination policy for high-risk infants then subsequently
for all newborns. All other regulatory interventions primarily focused
on provision of funded vaccine coupled with mandatory vaccination
Title/ First author/
year of publication
Primary care
strategies to
improve childhood
immunization
uptake in
developed
countries:
systematic
review, Williams,
N., 2011 [2]
89
Description of the reviews
General
Inclusion /
Purpose and
Exclusion criteria
setting
qualitative)
To conduct a
systematic
review of
strategies to
optimize
immunization
uptake within
preschool
children in
developed
countries
Inclusion:
Experimental
studies reporting
original research
including RCTs,
NRCTs, before
and after studies
and ITS studies
Targeting
population of
children under the
age of 5 years
living in
developed
countries
Published from
inception to 1 June
2010
English language
Exclusion:
Studies for which
the full article was
not available, and
studies that did not
contain any
original data
Main
outcome
measure
Nb of
studies
included
Quality
assessment
of studies
Main conclusions
policies for health care workers (HCWs) and were implemented at a
jurisdictional and/or organizational level. The small number of studies
showed limited effectiveness of this strategy.
Increase in
the
proportion
of the
target
population
up to date
with
standard
recommend
ed
universal
vaccination
s
46
Reported
Parental reminders have been shown to have an overall positive effect
on immunization uptake. These effects have been reported with both
generic and specific reminders and with all methods of reminders and
recall.
The limited number of studies precludes from reaching an evidencedbased conclusion on the effect of parental education interventions on
parental behavior.
Only one study concerned patient-held records and did not
demonstrate a significant difference between usual care and a homebased record booklet
Provider reminder/recall strategies, provider education and provider
feedback shown to have a positive effect on immunization rates.
Multicomponent interventions shown a positive effect on
immunization rates. It is not possible to distinguish which component
of the intervention has had the greatest effect on immunization rates.
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Ward, K., et al., Strategies to improve vaccination uptake in Australia, a systematic review of types and
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Sadaf, A., et al., A systematic review of interventions for reducing parental vaccine refusal and vaccine
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Glenton, C., et al., Can lay health workers increase the uptake of childhood immunisation? Systematic
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Higgins, J.P.T. and S. Green, Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0
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Appendix A6C.1 Vaccine Hesitancy Landscape Analysis
VaccineHesitancyLandscapeAnalysis
List of key players working on the issue of Vaccine Hesitancy§
SAGE Working Group on Vaccine Hesitancy
July 2014
Background:
Vaccinehesitancyisoneofseveralconceptsandideasthatrelatetothedemandsideofvaccineusage.
Vaccinehesitancyisanemergingterminthediscourseondeterminantsofvaccineacceptancewhereuptakeofa
vaccineorimmunizationprogrammeinacommunityislowerthanwouldbeexpectedinthecontextof
informationgivenandservicesavailable.Vaccinehesitancyisinfluencedbyacomplexnetworkoffactorsincluding
issuesofcomplacency,convenienceand/orconfidenceinvaccine(s)orimmunizationprogrammethatmayresult
inrefusal,delayoruncertaintytowardssomeorallvaccines.Thesefactorswhichinfluencevaccineacceptance
varybysettingandresponsesneedtobelocallyassessed.
Thislandscapeanalysisattemptstotakearelativelybroadviewofvaccinehesitancybyincludingactors
workingontheissue.Thepurposeofthisdocumentistostimulateacontinuouscompilationoforganizations
involvedinvaccinehesitancywork.Theintentionisthatthelistbecomesmorepopulatedandevergreenas
stakeholders,organizations,institutesandcommunitiesrespondwithsuggestedadditions.Thisregularlyupdated
resourcecouldbepresentedinformofawikiapproachinordertofostercollaborationbetweenthedifferent
playersinthefieldofvaccinehesitancy.
Objectives:
Allowtoidentifywhatorganisationsareworkingontheissueofvaccinehesitancyinvarious
settings/countries.
Allowthoseworkingontheissueofvaccinehesitancytoidentifypotentialpartners,donorsandcollaborators
inthefield.
Allowpeopletoidentifytheregionswhereworkisbeingdoneonvaccinehesitancyandwhatkindofworkis
beingdoneineacharea.
Bearegularlyupdatedresourceonworkcurrentlybeingdoneinthefieldofvaccinehesitancy
Helpidentifyresearchandfundinggaps—particularlyincountrieswheretherearemoresignificantvaccine
hesitancyissues.
•
•
•
•
•
Methods:
§
No claims can be made about the completeness or adequacy of the contents of this document .
92
Five categories and four sub-categories of actors were determined to represent the groups working on the
issue of vaccine hesitancy, including Government (national and regional), Not-for-profit, Donors, Research
Organisations and Multinationals. An Other category was included to represent any actor that did not fit in the
above categories but was still producing important work related to vaccine hesitancy. Industry was not included as
its own category in this framework. Although industry has a major stake in vaccine hesitancy, industry vaccine
groups share similar interests in combating vaccine hesitancy and therefore conduct comparable work on the
issue. Consequently, limited benefit is seen in analysing each member of vaccine industry individually. Instead, the
vaccine industry was included as one entity in the ‘other’ category, so their work and interests as a group may be
presented in the Landscape Analysis.
Excluded were overarching concepts, frameworks or strategies addressing vaccine hesitancy as a subcomponent only and which are not a solitary entity but composed of different organizations, stakeholders or
collaborators. In this context especially the “‘Decade of Vaccines’ Collaboration/ Global Vaccine Action Plan” needs
to be mentioned16.
Areas of work:
7 areas of work and/or interest were identified being carried out by actors working on the issue of vaccine
hesitancy, these included:
•
•
•
•
•
•
•
research
policy recommendation
intervention
education & promotion
collaboration
goal setting
social mobilisation
Search strategies:
Two main strategies were used:
1. Literature Search
a. Databases/Search engines used:
i. Google: Canadian (google.ca), United States (google.com), United Kingdom
(google.co.uk) and Hong Kong (google.com.uk)
• First 5 pages of google were searched for relevant actors
ii. Pubmed
iii. Refworks database for the systematic review on the rubric of trust and confidence
in vaccines currently being produced by the London School of Hygiene and Tropical
Medicine (LSHTM).
iv. WHO database: Global Information Full Text project (GIFT), more than 10,000
priced and open access journals
b. Search terms
i. Google (Canadian, US, German and UK), GIFT and Pubmed
• Used the following search terms: vaccin*, immunization, shot AND hesitan*,
resistan* refusal, confidence, acceptance, promotion AND initiative* OR
organization* OR strateg*
• Used the following search terms: impf*, immunisier*, AND gegner, skepsis,
verweiger*
93
ii. Google (Hong Kong)
• Used the same search terms as above, translated into Chinese:
- 疫苗=vaccine
- 犹豫=hesitant/hesitancy
- 抗拒=refuse/resist
- 信心=confident/confidence
- 接受=accept/acceptance
- 研究=research
- 组组=organization/institution
iii. Refworks
• Searched full database, using term: vaccin*, immunization, shot AND
hesitan*
2. Snowballing technique
Furthermore, we obtained unpublished information through personal communication with colleagues and experts, i.e.
at conferences addressing vaccine hesitancy.
a. Asked main players working on the issue of vaccine hesitancy (i.e. people in SAGE WG on
vaccine hesitancy, and players identified through initial literature search) and colleagues
familiar with regional/local circumstances
i. Feedback from:
• Julie Leask, University of Sydney
• Eve Dubé, member SAGE working group (WG) on vaccine hesitancy
• Heidi Larson, member SAGE working group (WG) on vaccine hesitancy
• Noni MacDonald, member SAGE WG on vaccine hesitancy
• Susan (Yuquing) Zhou, member SAGE WG on vaccine hesitancy
• Mahamane Laouali Manzo, member SAGE WG on vaccine hesitancy
• Dr. Bettinger, vaccine researcher at the Child & Family Research Institute at
the BC Children's Hospital and UBC, Canada
b. Based on these responses collaborators and affiliates of players of vaccine hesitancy that were
mentioned were looked up and it was determined if/how they were involved in vaccine
hesitancy.
c. The main players working on the issue of vaccine hesitancy also provided additional contact
information for other actors working on this issue.
Inclusion/exclusion criteria:
Inclusion:
i. Actors doing work in at least two of the seven areas of work/interest specified in the
introduction.
ii. Actors give specific examples of activities they are engaged relating to the issue of
vaccine hesitancy (i.e. not simply stating general mandates).
Exclusion:
iii. Actors promoting vaccine hesitancy or who are part of the anti-vaccination lobby.
iv. Actors that have not worked on the issue of vaccine hesitancy in the last 5 years
94
Results:
Table 1. Key actors working on vaccine hesitancy
Categories
Key Actors
Gov.
China CDC
(CCDC)
National
Areas of
**
Work/Interest
• Research
• Policy
Recommendations
• Interventions
††
‡‡
Actions
Region
• Research:
17
o Survey of KAP (knowledge, attitudes and practices) of measles (MOH, WHO, UNICEF)
o Person to person communication intervention strategies16 (MOH, WHO, UNICEF))
o Evaluation of parents KAP on immunization16 (MOH, WHO and US CDC)
• Social marketing campaign
18
o 25 April- Children’s Immunization Day (MOH, CCDC and provincial health bureau and
China
provincial CDC)
o Mass Communication Intervention: Information sheets/brochures for parents and
19
caregivers, to address any vaccine concerns. (MOH, CCDC) Religious leader to address
vaccine benefits in the sermon.
Guide providing info about general knowledge, the benefits of vaccination,
situations when not to receive vaccination, preparation work for parents, adverse
events, etc. (MOH, CCDC)
China MOH
• Research
• Interventions
• Education &
Promotion
**
• Social Marketing:
o Immunization Day (MOH ,national wide health bureau and CDC and government)
China
Theme: Vaccination is the responsibility of each household in 2012, each year has
different theme based on the priority of work (MOH)
• Promotion methods (CCDC and Local CDC)
o Central governor and Local governor attend initiating ceremony
o Improve awareness and promotion through competitions about vaccine knowledge,
expert visits, as well as art and cultural performances (CCDC)
o Involvement of organisational leaders, including attending vaccine promotion
activities, improve cooperation between education and social media departments,
motivate village leaders and committee members to promote to the community
about the efficacy and safety of the vaccine(MOH, PROVINCIAL HEALTH BUREAU
and CDC)
o Arrange visits to rural areas and visits of minorities which health information may
not reach conveniently (CDC)
o Enforce education to village committees, village doctors, school teachers, and parents
CDC
Areas of work/interest within vaccine hesitancy including: research, policy recommendation, intervention, education/promotion, collaboration, goal setting, social mobilisation.
Actions: examples of current vaccine hesitancy activities the actors are engaged in
‡‡
Where (country/setting) where the organization is based and/or where their work on vaccine hesitancy is focused.
§§
Only organization that consistently collaborated on vaccine hesitancy or worked on key project related to vaccine are shown in the ‘Collaborators and Affiliates’ section.
††
95
Collaborators
§§
and Affiliates
• Provincial
health bureau
and CDC
• WHO
• US CDC
• UNICEF
China Ministry
of Health
(MOH)
• China CDC
• Provincial
health bureau
and CDC
• Central and
local
governments
Categories
Key Actors
Department
of Health,
Belize
• Policy
• Intervention
• Research
Federal
Centre for
Health
Education
(Bundeszent
rale für
Gesundheitli
che
Aufklärung,
BZgA)
National
Centre for
Immunisatio
n
Research
and
Surveillance
* (NCIRS)
• Education &
African
region:
Ministries of
Health and
Communicati
on
(Niger,Benin,
Nigeria,Mali,
Burkina
Faso,Kenya,
Guinée
Conakry)
96
Areas of
**
Work/Interest
Promotion
• Research
††
Actions
o Systematically collect and manage information of promotion activities CDC
Please note that many of these projects were undertaken in concert by both the China
Department of Health and the China CDC.
• Belize deployed a country-wide fully integrated patient centred health information system
20
with eight embedded disease management algorithms and simple analytics. This
public health strategy is set in place to then meet with all parents at their homes whose
children were not immunized in timely fashion.
• Health education and health promotion
• Research on parental knowledge, behaviour and attitude concerning vaccinations and the
21
need for information material
• Research
• Policy
• Workshops and conferences
22
o 2012- Ethical Issues in Immunisation Seminar
Recommendations
• Interventions
• Education &
Promotion
Presentation on ‘How far can government go in promoting vaccination?’ and ‘A
little bit more ethics on power an persuasion in immunisation’
• Social Research
o Descriptive, identifying immunisation-related beliefs, attitudes and practices of
23
consumers and health professionals, as well as mass communication research.
24
Survey tracking parental attitudes to vaccination
25
MMR Decision Aid
• Used to help parents to decide whether to immunise their child with MMR the
vaccine.
• Policy
Recommendatio
ns
• Intervention
• Education&
promotion
• Collaboration
• Goal setting.
*Please note that the NCIRS is directly linked with the University of Sydney, however
because of its varied work on the issue of vaccine hesitancy it was included as its own actor.
• Solemn declaration by President (swearing on the Koran at Niger) on the safety of the
vaccine to overcome reluctance
• Launching ceremonies of immunization campaigns by heads of state: (Niger, Nigeria,
Benin, Burkina Faso, Mali).A meeting is organized with all stakeholders are taking part.
Media coverage of this meeting is broadcasted.
• Media coverage of immunization sessions where families of authorities(health and
government) are vaccinated: Niger, Nigeria
• Integration of home visits in the “minimum package” of health center service delivery:
Niger, Benin, Burkina Faso ,Mali
• Broadcast television radio messages explaining the different vaccinations during the EPI
immunization schedule and the importance of respecting it (reports by religious
association, chief associations and MOH): Niger, Benin, Burkina Faso ,Mali, Nigeria
• Capacity building of EPI managers: WHO and UNICEF support it in most of African region.
‡‡
Region
Belize
Germany
Collaborators
§§
and Affiliates
Canadian
Centre for
Vaccinology
• German
Ministry of
Health
• National
Public Health
Institute
Australia
• Australian
Technical
Advisory
Group on
Immunisation
(ATAGI)
• Australian
Government
Department of
Health and
Ageing
• University of
Leeds
Africa
• UNICEF
Categories
Key Actors
Areas of
**
Work/Interest
††
‡‡
Region
Collaborators
§§
and Affiliates
with lean of UNICEF) and distribution of educational media information to raise
awareness (illustrated flip charts, booklets, posters) among health workers, religious
and chief association
26
• Information on the 20 most common prejudices against vaccines
27
• Publication on the acceptance of vaccination in parents.
• Bi-weekly service hotline for physicians answering specific questions related to
28
vaccination
Germany
• Federal States
• Policy/Recomme
• Project: Strategic Directions for the Development of the vaccination program and
Romania
ndation
• Research
Promotion of vaccination
Identifying issues related to vaccine hesitancy and developing a national strategy with best
practices and recommended methodologies to tackle caregiver hesitancy.
• Joint Committee on Vaccination and Immunisation (JCVI)
29
o Research on attitudes on influenza vaccination in children
• Immunisation Market Research Section
o State: “feedback on attitudes and awareness of immunisation is vital to help inform
30
and shape the work” on successfully promoting and administrating vaccines.
31
o Parent tracking research and health professionals surveys
o Studies of attitudes towards HPV (e.g. for girls, mother, nurses administrating the
32
vaccine)
33
o Evaluation of vaccine hesitancy campaigns
• Arm Against Cervical Cancer campaign
A national media campaign “designed to inform mums and girls about the virus and
vaccination program, offer reassurance of the vaccine’s safety, counteract possible negative
34
press attention and maximise take up of the vaccine.”
• National Center for Immunization and Respiratory Diseases (NCIRD)
Online tool for Catch-up Scheduling for Childhood Immunization (www.vacscheduler.org)
• Funds collaborations and initiatives focusing on vaccine hesitancy:
35
o Immunization Action Coalition
36
o Vaccine Confidence Project (LSHTM)
•
Clinical Immunization Safety Assessment (CISA)
o To enhance public confidence in sustaining immunization benefits for all populations
Actions
• Production of information material (National EPI, National Directorate of Health Education
Robert KochInstitutecentral
federal
German
institution
responsible
for disease
control and
prevention
Romania
National
Institute of
Public Health
UK
Department
of Health
• Research
• Education&
promotion
• Research
• Interventions
• Policy
Recommendations
US Centers
for
Disease
Control and
Prevention
(CDC)
• Research
• Interventions
• Policy
Recommendations
US
• Research
Department • Policy
of Health and Recommendations
97
• National Vaccine Advisory Committee (NVAC)
o Recommendations on Strategies to Achieve the Healthy People 2020 Annual Influenza
37
Vaccine Coverage Goal for Health Care Personnel
of Germany
• ECDC
UK
• Health
Protection
Agency
USA
• US
Department
of Health and
Human
Services
State public
health
departments
USA
CDC
Categories
Key Actors
Human
Services
Regional
Department
of Health
and
Wellness,
Nova Scotia,
Canada
Institut
National de
Santé
Publique de
Québec
• Regional
governors,
prefects and
mayors
• Regional
and
department
al public
health
direction
• Traditional
98
Areas of
**
Work/Interest
• Goal Setting
• Education &
Promotion
• Research
• Interventions
• Policy/Recomme
ndation
• Research
• Intervention
• Goal setting
• Education &
Promotion
• Interventions
• Policy
††
‡‡
Actions
o Vaccine Hesitancy working group established
Region
Collaborators
§§
and Affiliates
Nova
Scotia,
Canada
• Can Centre for
38
In report, individuals raised concerns over adverse events, vaccine
effectiveness, vaccine safety, etc.
39
o A Pathway to Leadership for Adult Immunization: Recommendations of NVAC
Identified 9 categories of barriers to adult immunization, including ‘lack of
public knowledge’, ‘health literacy’, and ‘concerns about adverse events’
One recommendation- increase ‘community demand for vaccinations’
40
• 2010 National Vaccine Plan
o Goal 3: Support communications to enhance informed vaccine decision-making
Priorities for implementation include “increase awareness of vaccines, vaccine-preventable
diseases, and the benefits/risks of immunization among the public, providers, and other
stakeholders”3
41 42
• Projects to decrease vaccine hesitancy: ,
o Campaign to mitigate pain with immunization based upon evidence– aimed at parents,
adults, HCP anxious about immunization
• Campaign to increase uptake flu vaccine by pregnant women
• Plan Québécois de Promotion de la Vaccination (February 2010)
43
o Action Plan for Vaccination Promotion- Phase II (April 2012)
Phase II addresses goals 3 and 4 of the action plan which related directly to vaccine
hesitancy
• Goal 3: Encourage positive attitudes toward vaccination among health
professionals and encourage such professionals to be vaccinated themselves
• Goal 4: Encourage positive attitudes toward vaccination in the general
population
To achieve these goals
• Identify knowledge, attitudes, beliefs and practices of general
population and health professionals,
• Identify interventions to encourage positive attitudes toward
vaccination
• Strategies to train health professionals on vaccination, and update their immunization
competencies
• Organization of meetings with communities around the reasons of vaccine hesitancy: MOH
and, religious and chief association. Discussions with community, religious and
traditional leaders, various associations,
• Organization of home visits by health centers through Community women: (Volunteer
Community mobilizes) Niger, Nigeria, Mali, Benin,Burkina Faso
• Organization of meetings in neighborhoods, villages and health centers: health workers,
religious association, traditional chiefs and the community health committee
• Debates and broadcast messages on local radio stations.
• Use of media for promotion and surveillance of campaigns: local radio, text messaging and
daily evening meetings during campaigns to spot and correct refusals and other
problems encountered (e.g. Guinée Conakry)
Vaccinology
HELPinKIDS
Canada
Québec,
Canada
• L’Université
Africa
• MOH
• UNICEF
Laval
Categories
Non-for-profit
Key Actors
and
religious
leaders
(Imams,
Pastors)
•Health
committees
California
Immunizatio
n Coalition
Canadian
Centre for
Vaccinology
Areas of
**
Work/Interest
99
‡‡
Region
Collaborators
§§
and Affiliates
• Providing rewards e.g. “hygiene kit during immunization session” in Kenya to women
whose children are fully immunized financed by MOH,UNICEF.
• Reward health centers with the best performance vaccination financed by MOH,UNICEF
• Education
• Improving immunization rates (coverage) for Californians of all ages and achieving
&Promotion
• Interventions
Healthy People goals relating to immunization rates across the lifespan.
• Offering leadership in policy development and advocacy with an emphasis on promoting
community based advocacy through support of local coalitions.
• Providing educational activities/opportunities for health care professionals, community
stakeholders and the public: e.g. shotbyshot.org
• Promoting use of immunization registries.
• Reducing health disparities and improving access to vaccines by addressing barriers that
prevent or limit access to immunizations.
• Virtual Immunization Communication Network (VIC Network) partnership between the
National Public Health Information Coalition (NPHIC) and the California Immunization
44
Coalition (CIC)
45
• Vaccine hesitancy, with specific focus on
o pain mitigation,
o school based vaccine programs
o hard to reach populations and their hesitancy,
o health care professional undergrad curriculum
o HCP hesitancy for flu vaccine policy and hesitancy
• Research
• Education &
Promotion
Canadian
• Education
Immunizatio &Promotion
n Research
• Research
Network
(CIRN)
Canadian
• Research
Association • Intervention
for
Immunizatio
n Research
and
Evaluation
Canadian
Pediatric
Society
Canadian
Nurses
††
Actions
California,
USA
• National
Canada
• Variety of
Public Health
Information
Coalition
(NPHIC)
• CDC
local, regional
and national
partners- both
NGOs and
govt’s
• The CIRN includes the Social Sciences and Humanities sub-network (SSH) which will focus
on the topic of vaccine hesitancy
46
47
• CAIRE actively participates and promotes vaccine related investigations
• Organisation of vaccine-related conferences
• Immunization Competencies Education Program (ICEP), training for Health Professionals
• CAIRE offers a "second scientific home" to researchers who work in the field of applied
Canada
Agency of
Canada (Centre
for
Immunization
and Respiratory
Infectious
Diseases)
vaccinology.
• Education&
• Education materials for parents and health care professionals: Caring for kids
Promotion
Collaboration
• Education&
Promotion
Collaboration: provincial governments, PHAC at the Federal Government
48
49
• Position statement of vaccination of nurses against influenza
50
• Immunization myths and facts
• Public Health
Canada
Categories
Key Actors
Association
COMMVAC
project
Global Polio
Eradication
Initiative
Areas of
**
Work/Interest
• Interventions
• Education&
Promotion
• Research
• Research
• Interventions
• Education
&Promotion
• Research
Internationa
l Vaccine
Access
Center
(IVAC)*
• Research
• Education
&Promotion
††
‡‡
Actions
Region
51
The COMMVAC project aims to:
• build research knowledge and capacity to use evidence-based strategies for improving
communication about childhood vaccinations with parents and communities in low- and
middle-income countries (LMICs)
• build the evidence needed to support the implementation of effective communication
interventions
• translate this evidence into guidance for policymakers in LMICs on communication
strategies to improve childhood vaccination uptake
• Data and monitoring
Household survey asking about reasons why child was not immunized (e.g.
53
refusal- religious belief, vaccine safety, no felt need)
• Polio Pipeline: KAP studies- understanding barriers to immunization
54
Studies conducted in Nigeria, India, Pakistan in 2008 and Afghanistan in 2009
55
• National Polio Surveillance Programme in India :
•
Resistancy issues in endemic areas
•
Surveys looking at what children are not being vaccinated and
why?
Various
52
affiliates
Polio
infected
countries
National
Association
offices of
International
governments
• LSHTM
• Assessing how to increase demand-side strategies which could contribute to achieving
• Johns Hopkins
high and timely vaccine coverage: Mobile Solutions for IMmUnization (m-SIMU)
• Landscape Analysis of Routine Immunization (LARI)in Nigeria:
o The project aims to identify the key supply- and demand-side bottlenecks to routine
immunization coverage in Nigeria, and determine drivers of low coverage and
57
inequalities
Bloomberg
School of Public
Health
• PATH
• WHO
• CDC
• The Global
Coalition
Against Child
Pneumonia,
• Wide variety
of national
partners
56
100
• Education
• A national non-governmental, professional, health, consumer, government and private
&Promotion
• Interventions
• Research
sector organization with a specific interest in promoting the understanding and use of
vaccines recommended by the National Advisory Committee on Immunization. The goal
of Immunize Canada is to contribute to the control/elimination/eradication of vaccinepreventable diseases in Canada by increasing awareness of the benefits and risks of
immunization for all ages via education, promotion, advocacy and media relations.
• Development of the ImmunizeCA App, for individuals to easily record and store vaccine
58
information and access vaccination schedules
59
• Immunization fact sheets
• Advocacy
• Traditional chief and religious (Muslim and Christian) have an Association in most African
countries. Taking the example of Niger: National association of traditional chiefs named
Association des Chefs Traditionnels du Niger(ACTN) or Association Islamic du Niger
• Policy/Recomme
ndation
• Intervention
• UNICEF
• WHO
• US CDC
• Rotary
• National
*Please note that the IVAC is directly linked with the Johns Hopkins Bloomberg School of
Public Health, however because of its varied work on the issue of vaccine hesitancy it was
included as its own actor.
Immunize
Canada
Collaborators
§§
and Affiliates
Africa
MOH, WHO
UNICEF
Categories
Key Actors
traditional
chief and
religious
leaders.
National
Foundation
for
Infectious
Diseases
(NFID)
Areas of
**
Work/Interest
101
‡‡
Region
(AIN).
• Education &
Promotion
• Collaboration
• Professional educational program on immunization twice per year – 3 hours devoted to
60
• Mission of TVI is to increase vaccine uptake and to reduce vaccine preventable disease
VAX
Northwest
• Social marketing campaign
• Research
• Intervention
• Promotion &
• Research
• Intervention
USA
CDC and others
Pakistan
• International
Vaccine
Institute
• Ministry of
Health – Govt of
Sindh
• Expanded
Programme on
Immunization
• Ministry of
Education –
Govt of Sindh
• City District
Government
Karachi
hesitancy each course for now > 5 years
Trust for
• Interventions
Vaccines
• Education
and
&Promotion
Immunizatio
n (TVI)
Bill and
Melinda
Collaborators
§§
and Affiliates
• Advocacy on media
• Preaching in villages
• Face-to-face contact with reluctant individuals
Education
Donors
††
Actions
incidence in Pakistan by creating public demand for vaccination and immunization:
• Several mass vaccination campaign against typhoid fever of children and adults in towns in
61
the province of Karachi
• Seminars e.g. With School heads on typhoid fever awareness, with paediatricians on
62
pneumococcal disease or administrations of day-care centers.
63 64
o Increase timely immunizations from birth to age 24 months in Washington State ,
Focus: vaccine hesitant parents
Provider toolkit
65
Outreach to parents/social norms
The organisation is using social marketing strategies to develop a provider and a
community based intervention. Data on the success of both interventions will be
available in 2015 although there is already some early indication of success for the
community intervention: One state wide childcare co-op is changing policy –
immunization records will be collected and reported. To quantify intervention
success specifically with regard to hesitancy, parents are surveyed before and after
interventions using Doug Opel’s hesitancy index
• Funding
66
o Initiatives related to vaccine hesitancy, as well as vaccine acceptance and promotion
Washingt • Within Reach
on
Immunization
State, USA Action Coalition
of WA
• Washington
State
Department of
Health
• Seattle
children’s
hospital
• Community
pediatric
foundation of
Washington.
Global
• Wide variety of
global partners
Categories
Key Actors
Gates
Foundation
Research
Organisations
Robert
Wood
Johnson
Foundation
Harvard
University
Areas of
**
Work/Interest
• Education &
Promotion
• Research
• Intervention
• Research
• Collaboration
John
• Research
Hopkins
• Collaboration
School of
Public
Health
(JHSPH)
London
• Research
School of
• Intervention
Hygiene and • Promotion &
Tropical
Education
Medicine
Ottawa
• Research
Hospital
• Education &
Research
Promotion
Institute
Sherbrooke • Research
University
• Education &
(Quebec)
Promotion
University of
British
Columbia
(Vaccine
Evaluation
Center)
University of
Erfurt
102
††
‡‡
Actions
Region
E.g. Vaccine Confidence Index from LSHTM (global surveillance system to identify
and track rumours/misinformation related to immunization.
o Supporting organisations that are working in the area of vaccine hesitancy.
E.g. WHO, UNICEF, LSHTM
• Grants
67
o Funding publications and research
E.g. ‘Protecting public trust in immunization’
• Working with the American Academy of Arts and Science on a vaccine hesitancy project.
The American Academy of Arts and Sciences is planning a meeting for the fall 2014 to
explore and hopefully usefully define research questions relating to trust in vaccines
and vaccine hesitancy, which, if they received support from other sources, might enable
some rational decision policy making to enable useful information to be presented to
multiple groups key to immunizing children. Thus far the planning has been done with
input from Ed Marcuse and Seth Mnookin, along with people at the Academy.
• Research parental attitudes, studied the effectiveness of providing vaccination education
materials to pregnant women and women who have just delivered to see if that would
make them less hesitant. He has also collaborated with the CDC and Kaiser on several
studies.
• Vaccine Confidence Project
68
USA
USA
USA
• Wide variety
of global
partners
Canada
• Book title on Vaccine Hesitancy (working title): Cultural and Religious Roots of Vaccine
Promotion
• Research
• Education &
• Workshop on culture-sensitive health communication in May 2014
• Call for papers on improving medical decision making through cultural-sensitive health
71
• CDC
• Kaiser
Permanente
Canada
Hesitancy: Explanations and Implications for Canadian Health Care.
Objectives and target readership: 1) Report on various aspects of phenomenon of
vaccine hesitancy (VH) and its features; 2) Propose theories for understanding VH;
3) Support public health (PH) practices and decisions for health professionals facing
VH. PH authorities, health professionals and graduate students are targeted.
• The main research themes involve disease burden studies, vaccine clinical trials, and
Canada
studies to fine tune public immunization programs, including ongoing assessment of vaccine
safety
• Research
• Education &
• American
Academy of
Arts and
Science
UK
Symposium on Public Confidence in Vaccines in April 2014: Building Trust, Managing
69
Risk
• MOTIV Think Tank: Motors of Trust in Vaccination
• Developing systematic review on vaccine confidence, acceptance, hesitance, etc.
70
• Research on evolution of controversies concerning pediatric vaccination
Collaborators
§§
and Affiliates
Germany
• University of
Victoria
(British
Columbia)
• Researchers
across Canada
Categories
Key Actors
Areas of
**
Work/Interest
Promotion
University of • Research
Leeds (UK)
• Intervention
University of • Research
Sydney
• Interventions
• Education &
Promotion
Multinationals
University of
Washington
School of
Medicine
Seattle,
Washington
European
Center for
Disease
Control and
Prevention
(ECDC)
UNICEF
• Research
• Promotion&
Education
• Research
• Education &
Promotion
• Research
• Policy
Recommendations
• Education &
Promotion
• Intervention
WHO
• Research
• Policy
Recommendations
• Collaboration
• Education &
Promotion
103
††
‡‡
Actions
Region
Collaborators
§§
and Affiliates
72
communication
• MMR Decision Aid (with NCIRS)
73
o Detailed Evaluation of a Childhood Immunisation Decision Aid (D.E.C.I.D.A study)
UK
• Working with the NCIRS and other partners on a variety of projects related to vaccine
Australia
74
hesitancy, acceptance and promotion.
75
o E.g. MMR Decision Aid Tool
• Provide classes related to vaccine hesitancy and acceptance
76
o E.g. Publication Vaccines in Public Health
Content- “risk communication and immunisation myths and realities”
• Research in the field of vaccine refusal/ attitude towards vaccination
o Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months
77
of age, and the Health Belief Model.
o Washington State Pediatricians Attitudes Towards Alternative Childhood Immunization
78
Schedules
• Multi-stakeholder meeting on Individual decision-making and childhood vaccination held
79
in May 2013, Stockholm, Sweden
• The meeting resulted in a “Call for papers: Multidisciplinary perspectives on vaccine
80
hesitancy and contemporary vaccination coverage
• Various publications, among other: Systematic literature review of the evidence for
81
effective national immunisation schedule promotional communications
• Works with GAVI on the Advocacy & Communication Task Force (ACTF)
• UNICEF works with governments, partners and communities to increase demand for
immunization
• Vaccine strategies include engaging communities:
o Communication strategies that include advocacy, communication, and social
mobilisation
o Rapid inquiry into attitudes about PCV and introduction in Rwanda
• Financial and technical support for evidence-based social mobilization and communication
for immunization e.g. in countries like Niger, Nigeria, Benin, Tchad, Guinée, Gabon)
• Strategic Advisory Group of Experts (SAGE) on immunization
o SAGE Vaccine Hesitancy Working Group (establ. March 2012)
• Publications and information:
o E.g. Behavioural Factors in Immunization (Department of Mental Health and
Substance Dependence
o Vaccine Safety Net
“websites providing information on vaccines which adhere to good information
practices”
• Surveys:
o EPI Coverage Survey
Reasons for immunization failure cluster form, includes reasons such as ‘fear of
side reactions’, ‘no faith in immunisations’, ‘rumours’, etc.
• University of
Sydney
• University of
Leeds
NCIRS
USA
Global
• Wide variety
of partners:
• Member states
• WHO
• Academia
Global
• Wide variety
of global
partners
• GAVI
• WHO
Global
• Wide variety
of global
partners
Categories
Key Actors
Areas of
**
Work/Interest
††
Actions
‡‡
Region
Collaborators
§§
and Affiliates
• Capacity building e.g. of mid-level managers (MLM)in most of African country
WHO EURO
• Intervention
• Collaboration
• Policy/
Recommendations
• Goal setting
Other
104
Vaccine
Industry
• Research
• Intervention
PublicPrivate
Partnership
• Research
• Education &
Promotion
• Developing TIP (Tailoring Immunization Programme) Toolkit to identify behavioural
Europe
determinants of vaccination (and barriers) and recommend promising practices to address
or respond to such barriers. Includes caregiver hesitancy and presents diagnostic
framework for pin-pointing reasons for acceptance, hesitancy and refusal.
• Vaccine Hesitancy as subcomponent of Communication Strategy
• Factsheets
o Talking with parents about vaccines for children’
o Understanding the risk and responsibilities of not vaccinating your child.
European Immunization Week media and caregiver publications : ie. 7 Key Reasons
to Vaccinate and documents dispelling the myths that generate hesitancy.
Launching a mobile phone app in 2013 to allow parents to track their child immunization
status, remind them to vaccinate on time, and serve as a recall system in countries where
physicians do not carry out this service. Addresses a consistently reported reason for
hesitancy: lack of reminder or recall system (forgetfulness/apathy)
Global
• European Federation of Pharmaceutical Industries and Associations (EFPIA):
82
o Sponsoring of educational website on vaccination
• GlaxoSmithKline (GSK) supports researchers working on vaccine hesitancy and the
development of an education tool on how physicians’ should address vaccine hesitancy
and resistance.
• Sanofi Pasteur is supporting researchers working on vaccine hesitancy
•
Development of a standardized tool to measure vaccine hesitancy together with
Imperial College. Goal of Vaxi Trends Attitudinal Barometer is to generate a
validated tool that can: measure attitudes and perceptions, and how they turn
83
into behaviours; understand drivers and barriers to adult vaccination .
Innovative Medicines Initiative (IMI) supports collaborative research projects and builds
networks of industrial and academic experts in Europe that will boost innovation in
healthcare:
ADVANCE project: Accelerated development of vaccine benefit-risk collaboration
in Europe. The goal of ADVANCE is to review, develop and test methods, data
sources and procedures which should feed into a blueprint of an efficient and
sustainable pan-European framework that can rapidly deliver robust quantitative
data for the assessment of the benefits and risks of vaccines that are on the
84
market.
• Variety of
partners
• Variety of
partners
• Variety of
partners
Discussion:
It is important to note some specific attributes and limitations of this framework. Vaccine
hesitancy is an English term, with possibly no direct translation into certain other languages. Hence,
given the search strategy, this review has a strong focus on English-speaking countries or those
publishing/making available the information in English language though Working Group members
were asked to contribute in order to extend research to languages other than English. Through
request by stakeholders, the envisaged wiki-approach would allow active inclusions of these into
the list. This approach would ensure that additional stakeholders are reflected in the landscape.
A broad variety of groups focusing on the promotion of vaccines and therefore addressing
vaccine hesitancy in the population were found, yet according to our inclusion/exclusion criteria
we only listed groups focusing on generating research/studies or implementation/evaluation of
interventions where specific examples on the scope of their work could be identified.
There were several cases where actors and their interests could potential fit in more than
one category. For instance, as CDC is both a subsidiary of the US national government and it donates
money it could have fit in either the Governmental- National Category or the Donors category. In
these cases the actors were organised based on how they identify themselves, and in which of the
categories they produce most of their work on the issue of vaccine hesitancy. Therefore, in the case
of the CDC, they were placed within the Government- National category, as they identify themselves
as a major operating component of the Department of Health and Human Services in the US
government and produce most of their work on vaccine hesitancy as a part of the US government.
Furthermore, many of the projects on the issue of vaccine hesitancy were conducted with
the help of collaboration between multiple partners. This collaboration can make it difficult to
demarcate which organisations are working on which vaccine hesitancy projects. In these cases
organisation taking the lead on the project were tried to be identified and classified the action
under them. If two groups were highly connected it was noted that many of their projects would be
interlinked in the action section.
Retrieving information on low- and middle income countries conducting work on the issue
of vaccine hesitancy was difficult to find, possibly due to language or publication issues. Therefore
Working Group members were asked to share their knowledge on country activities.
The above framework illustrates that many advisory committees and organizations have
started to deal with the issue of vaccine hesitancy, including encountering and defining the problem
of lack of confidence in vaccines, gathering information on the problem and suggesting potential
strategies to deal with this issue. However, although organisations are starting to view vaccine
hesitancy as an important topic many organizations discuss and highlight the issue without making
meaningful contributions (e.g. research, interventions, recommendation). In fact, many
organizations working on vaccines state in their mandates that they will work to promote the use
and acceptance of vaccines among both the public and health professionals. However it is rarely
specified how they will achieve this vaccine demand section of their mandate. Few examples of
current projects relating to vaccine promotion/acceptance are given.
105
This landscape analysis, along with the development of indicators of vaccine hesitancy,
demonstrates that there are not many global vaccine reporting or surveillance systems currently
measuring demand-side indicators, such as vaccine hesitancy. In addition, most of the vaccinerelated work is on supply side criteria, rather than demand-side criteria. Most projects focus on
vaccine development, production and safety, as well as health systems strengthening, whereas only
a few projects focus on the demand-side factors (e.g. vaccine acceptance, confidence and hesitancy).
106
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110